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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street.Stockton.CA 95202-3029 Telephone:(2~09)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd ApPLICATION FOR A TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK I SITE LOCATION:DATE:11'2--1 I 10 PROPERTYOWNER NAME:~~n,n (\y)fJ.bri/() PROPERTYOWNER MAILING AoDRESS:~N.O.a/+hJvl.Ptvv CITY/STATE/ZIP:~c It-tun ,c A q S'b I ::::; 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 th~euse.J / CERTIFIED By:V'(15 1 2--1 I 0 PROPERTYOWNER SIGNATURE DATE FOR EHOUSEONLY ISeotic System Historv/Permit SummarY Permit#;22-stlb Date:101,~',cq p~~OOriginallnsfallation ~pair oReplacement oAddition Permit #:-,b -101 tf Date:,I ,0 (~17 oRepair oReplacement ~ddition oOther oRepair oReplacement oAddition oOther Permit#: Permit #:Date: Date:oRepair ORe placement oAddition oOther Permit#: Reuse Conditions oRepair oReplacement oAddition oOther ,~~nn _ Date: 10 AGE OF REsIDeNTIAl SYSTEM: lESS THAN Five (5)Vears Old o o Re-Connection Inspection Required 1111 A_ LoAlSEOFRESIDENTIAlSYSTEM: BETwEEN Five (5)and Ten (10)Vears Old o History of Failures -Additional Disposal Field Installation,,"'"I"..••d Comments)o Condition of System Evaluation/Inspection Required ENVIRONMENTAL HEALTH ORe-Connection Inspection Required PERMIT/SERVICES 1il AGE OF RESIDENTIAL SYSTEM: Over Ten (10)Vears Old o History of Failures -Additional Disposal Field Installation Required (See Comments)IConditionof System Inspection Required Disposal Field Reuse Expansion Required (50%of existing system) Re-Connection Inspection Required ~ o Commercial System:To be evaluated on a case by case basis based on scope of proposed project. Additional evaluation.improvement.and reporting requirements may be applicable. Comments:r e«JA-.h IJ(AAH I 7--'VICoaaA-.'2-'fl.1"lI!~A 4e:riJI ..5 -~~~.i. o Consultation Service R~u~~Septic Repair Permjt Req~ed 0 Septic Repair Permit May Be Required Per Building Permit Conditions REvIEWED By:<.......~/..P//'4')~///p7'~Q'LU --REGISTEREDEIMRoHIoENTAL.HEALTH SPeClAUST 'I Date: PE SC RECEIVEDBY CHECK#/AMOUNT DATE SERVICE REQUEST#INVOICE#PERMITID#CODE CASH••REMIT~D , 1J2I:h ,.---~/~/~/'d ~1//77//0 SZooho/J(J}'"l /,I Application for Temporary Waiver to Destroy Septic TankEH42'{)21 8/2512009