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Opg�!N c SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />.• -- Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�gtiFORia�P APPLICATION FOR A TEMPORARY WAIVER <br />FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: / _, CITY: DATE: <br />PROPERTY OWNER NAME: APN. Z!o <br />PROPERTY OWNER MAILING ADDRESS: <br />CITY/STATE/ZIP: �' ('' - PHONE: <br />Intent to Rebuild/Replace Statement <br />I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for <br />demolition, as indicated on the demolition permit application, within three (3) months from the date of demolition, and to <br />complete the construction and final the building permit within one (1) year from the date of demolition. <br />Septic Tank Abandonment Statement <br />I understand and acknowledge that should I fail to obtain a building permit within the above noted time period, the septic <br />tank will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD <br />at that time. <br />Reuse Conditions Statement <br />I understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced <br />structure, as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of <br />the rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply <br />with these conditions for the septic system reuse. <br />CERTIFIED BY: <br />PROPERTY OWNER SIGNATURE DATE <br />FOR EHD USE ONLY <br />_ <br />Septic S stem Hlisto /Permit Summa <br />Permit 9: <br />Q� � <br />Date: <br />� p <br />Ori EI Installation ❑Repair ❑Replacement ❑Addition <br />Permit #: <br />Date: <br />[]Repair ❑Replacement []Addition []Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement []Addition []Other <br />Permit #: <br />Date: <br />❑Repair []Replacement ❑Addition []Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Reuse Conditions <br />AGE OF RESIDENTIAL SYSTEM: <br />r7Re-ConnectionInspection Required <br />LESS THAN Five (5) Years Old <br />❑ History of Failures - Additional Disposal Field Installation Required (see Comments) <br />AGE OF RESMENTIAL SYSTEM: <br />❑ Condition of System Evaluation/Inspection Required <br />BET mEN Five (5) and Ten (10) Years Old <br />[] Re -Connection Inspection Required <br />4, AGE OF RESIDENTIAL SYSTEM: <br />❑ History of Failures - Additional Disposal Field Installation Required see Comments) <br />Condition of System Inspection Required <br />Over Ten (10) Years Old <br />Disposal Field Reuse Expansion Required (50F% <br />Re -Connection Inspection Required ,) JY ate, <br />To be evaluated on a case by case basis based on scope Ot proposed project. <br />❑ Commercial System: <br />Additional evaluation, improvement, and reporting rmqq;oq�way!WVpjicable. <br />Comments: --- -- PEE.MIlT/ c E <br />--mConsultation Sere Required ❑ ptic R air Permit Required Septic Repair Permit May Be Required Per Building Permit on tions <br />RIEWI WED BY:—Itl <br />EGISTERED ENVIRONMENTAL HEALTH SPECIALIST ate: <br />PE <br />CODE <br />SC <br />RECEIVED BY <br />CHECK#1 <br />CASH <br />AMOUNT <br />REMITXD <br />DATE <br />SERVICE REQUEST # <br />INVOICE # <br />PERMIT ID# <br />54l <br />EH 42-021 8/25/2009 —,r;, G "llI Application for Temporary Waiver to Destroy Septic Tank <br />