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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />2: - —ori— . •Z <br />600 East Main Street, Stockton, CA 95202-3029 <br />•' Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />coq..-.::• �P APPLICATION FOR A TEMPORARY WAIVER <br />�/FORS <br />FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: 7�� t S N t✓Sj (.i I. CITY L_^ V` J DATE: _- r <br />PROPERTYOWNER NAME: APN:71 <br />PROPERTY OWNER IfdG ADDRESS: <br />CITY/ TE IP: 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 condition for these tic syste reuse. <br />CERTIFIED BY: <br />- / r PROPERTY OWNER SIGNATURE DATE <br />FOR EHD USE ONLY <br />Septic System <br />Histo /Permit Summa <br />Permit #F: <br />;�(' /�' % �",f <br />Date: / <br />{90riginal 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 #1: <br />_1 <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />"Reuse Conditions <br />u AGE OF RESIDENTIAL SYSTEM: <br />❑ Re -Connection inspection Required <br />i_ESSTIiwv Five (5) Years Old <br />❑History of Failures -Additional Disposal Field Installation Required (see comments) <br />❑ AGE OF RESIDENTIAL SYSTEM: <br />AGEOFBETWEEN <br />❑ Condition of System Evaluation/Inspection Required <br />Five (TI and Ten (10) Years Old <br />❑ Re -Connection Inspection Required <br />❑ History of Failures - Additional Disposal Field Installation Required (see Comments) <br />AGE of RESIDENTIAL SYSTEM: <br />Condition of System Inspection Required <br />Over Ten (10) Years Old <br />r. Disposal Field Reuse Expansion Required (50% of existing system) <br />Re -Connection Inspection Required <br />Y] <br />To be evaluated on a case by case basis based on scope of proposed project. <br />❑ Commercial System: <br />Additional evaluation, improvement, and reporting requirements may be applicable. <br />Comments: y <br />❑_Consultation Service Required VISeptic Repair emit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions <br />� <br />REVIEWED BY: <br />_ <br />REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: <br />PE <br />CODE <br />SC <br />h.ECE!✓ED BY <br />CHECK#/ AMOUNT <br />CASH REMITTED <br />DATE SERVICE REQUEST # <br />INVOICE # <br />PERMIT ID# <br />I I i i <br />EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />