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'oPq ccs SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd cq�ikoRr'�P APPLICATION FOR A TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK CITY: DATE: J SITE LOCATION: f i _> i� �# I S r? . _ , c r PROPERTY OWNER NAME: 1 _ APN: l { PROPERTY OWNER MAILING ADDRESS: 19605 , . Ae'4191 CITY/STATE/ZIP: �', �, PHONE: AL1 Intent to Rebuild/Replace Statement I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for demolition, as indicated on the demolition permit application, within three (3) months from the date of demolition, and to complete the construction and final the building permit within one (1) year from the date of demolition. Septic Tank Abandonment Statement I understand and acknowledge that should I fail to obtain a building permit within the above noted time period, the septic tank will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD at that time. Reuse Conditions Statement I understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced structure, as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of the rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply with these conditions for the septic system reuse. CERTIFIED BY: () / Y p '9 PROP, RTY OWNER SIGNATURE DATE FOR EHD USE ONLY Septic System Histo /Permit Summary Permit* �, /lL �j "j r�"-� : ' Date: % j _ E10riginal Installation ❑Repair ❑Replacement ❑Addition Permit #: Date: []Repair ❑Replacement ❑Addition ❑Other Permit #: Date: ❑Repair []Replacement ❑Addition ❑Other Permit #: Date: ❑Repair []Replacement ❑Addition ❑Other ;Permit #: Date: []Repair[-]Replacement❑Addition ❑Other Reuse Conditions AGE OF RESIDENTIAL SYSTEM: ❑ Re -Connection Inspection Required LEss THAN Five (5) Years Old ❑ History of Failures - Additional Disposal Field Installation Required (see Comments) i9 AGE OF RESIDENTIAL SYSTEM: !- 1 ❑ Condition of System Evaluation/Inspection Required BETwEEN Five (5) and Ten (10) Years Old Re -Connection Inspection Required '. c'.; ,r{ r —_4 T �� ❑ History of Failures - Additional Disposal Field Installation Required (See Comments) ❑ AGE OF RESIDENTIAL SYSTEM: ❑ Condition of System Inspection Required I- 7-k £ Over Ten (10) Years Ofd ❑ Disposal Field Reuse Expansion Required (50% of existing system) I- ❑ Re -Connection Inspection Required ) - t"'' To be evaluated on a case by case basis based on scope of proposed project. ❑ Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable. Comments: :•,.-cf-7,A-t*,rJT 'z.ti:J .elf "� ; `-L F� lL rL ;;�i�+- - :, , A-(IA .2.J I I { .�� -A f '�/ .� .ti�:.� ''3- l , C ,i !- !_-'liF".t' f. . a i %�Fv 't /_�110 Consultation Service Required ❑ Septic Repair Permit Required S1 Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMEWTAL HEALTH SPECIALIST Date: PE sC RECEIVED BY CHECK#/ AMOUNT DATE REMITTED SERVICE REQUEST # INVOICE # PERMIT ID# CODE CASH �z�s LTA Roo 0 I., EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank