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t <br /> SAN JOAQUIN COUNTY <br /> _r ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Man Street, Stockton, CA 96202-3029 <br /> Telephone:(209)46£-3420 fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> :.r/ APPLICATION FOR ,A', TEMPORARY WAIVER <br /> FRow REQUIREMENT TO DESTROY ABANDONED SEP-tic TANK <br /> SITE LocATION-. C!T,. DATE. <br /> C <br /> PRCfiO n10VVNER NAME: L t APN: <br /> PRCrPct2YY J ItiPRIffifEI(. W6 f�.a <br /> Intent to Rebuild/Replace Statement,_-,' <br /> 4 i�:r Ely c� dis ttr -rt fs r#fyter7'#ion to obtain a building permit to rebuiid!replace the structure being proposed for <br /> demolition, as indicated on the demolition permit application,within three(3)months frorn the date of demolition, and to <br /> Conipleate the construction and final the building permit within-, one('#;i year srain'the elate of demolition. <br /> Septic Tank Abandonment Statement <br /> 1 understand and acknowledge that should 1 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 s HD <br /> at that lime. <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 rebuiitireplaced structure, i understand that I will be responsible for ail EHD enforcement costs should I fail to comply <br /> with i these C:onditio iS�3r the Septic:system reuse, <br /> CERTIFIED By, <br /> rsROPFR7-Y OWNER SIGNATURE DATc <br /> FOR 640 inn t5W.y - <br /> •�tic <br /> T face ent r <br /> _ _ 'Addition <br /> 4 isT# �w > te: 1 t.- R air�Replac entL-t�Clff.5o Gooier' <br /> �'�±i"�'it L�t�ra r �Repla rtent A�Icfittori Qtr <br /> r a ! i z..Ra it Le i rnerEt Q dpi idn j�Uitsa�r <br /> Z]RePair,DRvpiat �!Mdtt n t kher <br /> 4W F€ia Years Otd <br /> cc l FZ5=%A'1, . rMA: ..>o Failures Additionall Disposal Heid lns;alli tion R Uired( Commori►sj <br /> ` `� Five s{; }Y tt f Condition cif rstsri E tuatir iflnsp iso Required <br /> i t�e-Gt�nl�e�cfrr�l, lr?�ta�cti �sq�ired <br /> '_.r History of Fiiilum -Additional.visposat Fief fns#tafiation Required (See iment's) <br /> }f'Z`STE?Q: stition of Systefn Inspectton.Refired , <br /> )Sal new fi se E)�Paflsi €l tsi€ { %of existing,systeml <br /> l czrar is,�t Inspection <br /> Required', <br /> Tobe v tuatrd on a ::ase'by case iasis based on swee of proposed pi- <br /> Additional <br /> i Additional evaluatzn, improvement re-porting r uirp—meats maybe applicable. <br /> E$ s A <br /> septic i1�a*r l��'C#Filt'W.so. uired Per Suikfing Permit Conditions <br /> ¢3 �,. _ <br /> - _ Y? E}isriixrrii3��raYttSa?: s Bate: <br /> f' [g CHET-*(9° AMOUNT <br /> w l fscC.EivFs 8Y ! GATE sERVICE REQUEST# £ INVOICE# PERMIT If)# <br /> CoE <br /> CASH ?AfTTFO <br /> :ki;n,JI"Iirtofl(Crnr1,Waiver 40 Dc,$JrC;y Septic Tani, <br />