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SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> ": y< 600 East Main Street, Stockton, CA 95202-3029
<br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd
<br /> cP APPLICATION FOR A TEMPORARY WAIVER
<br /> <IFOR�
<br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK e*
<br /> SITE LOCATION: �Z ( 17 r D6`t� CRY'
<br /> PROPERTY OWNER NAME: r� APN: .Z r^
<br /> PROPERTY OWNER NW LING ADDRESS: UIN
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<br /> CIN/STATEOP: -� noPHONE:
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<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: Z 7—
<br /> PROPERTY
<br /> PROPERTY OWNER SIGNATURE DATE
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<br /> EH 42-021 $125/2009 Application for Temporary Waiver to Destroy Septic Tank
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