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6, //- <br /> SAN JOAQUIN COUNTY <br /> G ENVIRONMENTAL HEALTH DEPARTMENT <br /> 2 �—cri—, y <br /> W:.�vN, <j 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> cq<<FORNAPPLICATION FOR A TEMPORARY WAIVER <br /> FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: ,S'� �� c� CITY: Tl DATE: <br /> PROPERTY OWNER NAME: ^ t APN. <br /> 7% r;1 <br /> J c h r1 r,15 <br /> PROPERTY OWNER MAILING ADDRESS: <br /> CITY/STATE/ZIP: _ ( PHONE: <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,�qr the septic rstem reuse. <br /> CERTIFIED BY: A -Qiy1 2 -7 <br /> PROPERTY OWNER SIGNATURE DATE <br /> FOR EHD USE ONLY _ <br /> Septic System Histo /Permit SUMMary <br /> Permit#: �� - �a +.5 Date: - ; '[]Original Installation []Repair gReplacement❑Addition <br /> Permit#: Date: ❑Repair[]Replacement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement[]Addition❑Other <br /> Permit#: Date: ❑Repair[]Replacement❑Addition[]Other <br /> Permit#: Date: I ❑Repair[]Replacement❑Addition❑Other <br /> Rause Conditions <br /> AGE OF RESIDENTIAL SYSTEM: ❑ Re-Connection Inspection Required <br /> _ LESS THAN Five <br /> ® AGE OF RESIDENTIAL SYSTEM: ❑ History of Failures-Additional Disposal Field Installation Required (see Comments) <br /> BETWEEN Five(5)and Ten(10)Years Old ❑ Condition of System Evaluation/Inspection Required <br /> ❑ Re-Connection Inspection Required <br /> History of Failures-Additional Disposal Field Installation Required (See Comments) <br /> AGE OF RESIDENTIAL SYSTEM: Condition of System Inspection Required <br /> Over Ten(10)Years Old Disposal Field Reuse Expansion Required (50%of existing system) <br /> Re-Connection Inspection Required <br /> [] Commercial System: To be evaluated on a case by case basis based on scope of proposed project. <br /> Additional evaluation, improvement, and reporting requirements may be applicable. <br /> Comments: o( l t /I n ' 'Orp ki 6- DA il blr 'k -) <br /> ❑ Consultation Service Required ®Septic Repair Permit Required ❑Septic Repair Permit ay Be Required Per Building Permit Conditions <br /> REVIEWED BY: 'I/�� C7 - 1/-/ '7 <br /> REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: <br /> PE CH£-.CK#I AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> CODE SC RECEIVED BY CASH REMITTED __ i <br /> EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />