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QaDIN SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 2: ? <br /> Q: 600 East Main Street, Stockton, CA 95202-302 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> • �•. - �P APPLICATION FOR A TEMPORARY WAIVER <br /> q�ikoR°' FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> CITY: t ✓ DATE: (Dl i,l t <br /> SITE LOCATION: \ A, aAPN: <br /> ­QTOPERTY OWNER NAME:. <br /> ••PROPERTY OWN ,R MAIL NG ADDRESS: �• <br /> QITY/STAT Z P: J PHAN£� C <br /> c <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 <br /> m(f3) months <br /> he from <br /> ofthe date tion of demolition, and to <br /> complete the construction and final the buildingpermit within one (1)year <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/replace <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 un stand that I will be responsible for all EHD enforcement To��should I fail to comply <br /> with these con hs r the se `c s tem reuse. <br /> CERTIFIED - - <br /> PROPERTY OWNER SIGNATURE DATE <br /> FOR EHD USE ONLY <br /> Septic System Histo !Permit Summa — <br /> Permit#: Date: ❑Original Installation❑Repair❑Replacement❑Addition <br /> Permit#: Date: []Repair[]Replacement❑Addition[]Other <br /> Permit#: Date- Repair[]Replacement[]Addition[]Other <br /> Permit#: Date: Replacement❑Addition ❑Other <br /> Permit#: Date: j'► <br /> jt air f ent[]Addition[]Other <br /> Reuse Conditions q� <br /> AGE OF RESIDENTIAL SYSTEM: <br /> LESS <br /> Re-COnneCtion O <br /> _ LESSTHAN Five 5 Years Old <br /> ❑ History of Failures-Addi ation Required (See Comments) <br /> ❑ AGE of RESIDENTIAL SYSTEM: ❑ Condition of System Eva <br /> luation/ ty�n <br /> BETWEEN Five(5)and Ten(10)Years Old ❑ Re-Connection Inspection Required <br /> ❑ History of Failures-Additional Disposal Field Installation Required (See comments) <br /> AGE OF RESIDENTIALSYSrEM: ❑ Condition of System Inspection Required <br /> Over Ten(10)Years Old Disposal Field Reuse Expansion Required (50% of existing system) <br /> R,Re-Connection Inspection Required <br /> To be evaluated on a case by case basis based on scope of proposed project. <br /> ❑ Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable. <br /> Comments: L { <br /> 0 <br /> 7-CIL U a L 17i <br /> Consultation Service quired Septic Repair Permit Required ❑Septic Repair Permit May Be Required Per Building Permit Conditions <br /> REVIEWED BYj <br /> -� REGISTERED ENVIRONMENTAL HEALTH SPECIALIST �e <br /> PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERM-ID= <br /> CODE CASH REMITTED <br /> I— <br /> EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Sept <br />