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opo 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 /> e4' N`P APPLICATION FOR A TEMPORARY WAIVER <br /> �/FOR <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: S Z (cCk t�� Cnv: " A DATE: <br /> PROPERTY OWNER NAME: 7 1?S c <br /> t� <br /> AP—N �9—'2�vcC0i�—jI <br /> j-0 OWNERMAILING ADRESS: <br /> CI7Y/$TATE21P: S FP S 'ii nl Kpp <br /> Av, aA "(S 3 -,� PHONE: <br /> 2-p Intent to Rebuild/Replace <br /> Statement <br /> I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for <br /> demolition, as indicated on the demolition permit application, within three (3) months from the date of demolition, and to <br /> complete the construction and final the building permit within one(1) year from the date of demolition. <br /> Septic Tank Abandonment Statement <br /> I understand and acknowledge that should I fail to obtain a building permit within the above noted time period, the septic <br /> tank will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD <br /> at that time. <br /> Reuse Conditions Statement <br /> I understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuilt/replaced <br /> structure, as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of <br /> the rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these conditions for the septic system reuse. <br /> CERTIFIED BY: <br /> PROPERTY OWNER SIGNATURE <br /> ""'.µ.,aa. w« • 'EOR EH ONl�fa"�aN <br /> "', e.`dAkP"WSfi�Y 'M�.'S4trvR +� 9IyNY'hfi'i3Awda'S'.�a xS'R +"akCz:;n!ll:"DATE <br /> s1Tehx<Hlsto <br /> �efi� � 'fit e� �, ,•.� <br /> Pe ' Y _ # 4 fi� ❑ e� R'Re a e�e *®A+V ,It �ax.�e�� ,i'��� I�''4'"s <br /> Reuse"tCondltrons , �, P 4 , " �r �� <br /> � A'cE"PRT S s °nr a-Con"a Io ,$ ,spection equv � ��A`r <br /> I� 6E'D�' SID SStO P /i���t�lOn2�1 IIS S I'"«lel s��ri;1'�:rtag rn <br /> o '� n ste E�valua to ns Os I atip',h1' ' I ed(see�ComraQnts <br /> >r B = I {5) n ` e ? p e :� d "& - , •b� � .ec n e u r u �'r�; <br /> � s o n F'a�`"gy,�u""es r ,d%Ion I D7sposa rr=Ie ns liatlon'� uJ a (see,�om ent�y`' <br /> >' Ove&, 0 ears O / spo aI F e e�Exansl'o'� e u e 50°0 0 e Is gg s ste t, k ��°* <br /> '�� :� n�meraiat� e fl� �uaf onacase;�jcase,.baslsi ased sco =o, o setl�'��ec� ��rv�,�_ <br /> • %o,�a,e atr�,on, t�P�So.,�? e-.� r r!,n' requenents a,,,,�,e�aPPlcabe�.rt, <br /> A <br /> ��?P4�f3e �P I e9�e� ®�Sep5c�2epam Per�m�`MaY�,�� qulSetl a;Bulld�„°9t?���+��.�dlhon. ��; <br /> REYIEI4VED. <br /> w xY a x <br /> PE Sc RECENED BY CHECK#( AMOUNT <br /> CODE CASH REMITTED DATE SERVICE REQUEST# INVOICE# PERMIT[DO <br /> EH 42-021 6/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />