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q,•4• • rtl. SAN JOAQUIN COUNTY <br /> coD•,L..cD <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0i 600 East Main Street, Stockton, CA 95202-3029 <br /> �- Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> �d•• ::�••'�P APPLICATION FOR A TEMPORARY WAIVER <br /> e/FOft� <br /> ROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: :!� °y t G- it ( �Y Clrv: ,(' DATE: <br /> tl� <br /> ROPERTYO E NAA1E: C i f'g e 47 AVN: ,3 ry (jam <br /> PROPERTY OWNERJMAILy_919QRES p t <br /> ITY/STATE/ZIP: T i d <br /> 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 under tand that I will be responsible for all EHD enforcement costs should I fail to comply <br /> with these co dill n the septic Sys m reuse. / p <br /> CERTIFIED L3Yati�"" `(A-a, "A_... <br /> -P OPERTY QWN RSIGNATURE q DATE <br /> =`FOR EHD USE ONLY <br /> Se"tic's stem'Hi'sto 'IPermitSumma <br /> A (nitIM01 1 ❑original Installation❑Repair❑Replacement[]Addition <br /> Peimtt#y " Date (�Repair❑Replacemant[] iddrtign❑Other <br /> P.ermd#,' t)ate. ❑Repair❑Replagement❑Addition❑Other <br /> Eermrt# ' Date: C. ❑Repair[]Replacement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Reuse Conditions <br /> A0 OF RESIDENTIAL SYSTEM ° - <br /> lEssTHAN Five 5 Years Old '❑ R,e Connection Inspection Required <br /> ❑;AGE DF RE31oENTN1 SYSTEfd ❑ H,fstory of Failures Addihona(DiaposafField InstallationRequired Be(scomments> <br /> BETWEEN Five(5)and Ten(10)Years Old Condition of SystemEvaluation/Inspection Required <br /> Re-Connection Inspection Required <br /> OHistory"of Failures-Additional Disposal Field Installation Required(See comments) <br /> �kAeEoFRESIDENTIAL SYSTEM: Condition of System Inspection Required <br /> Over Ten(10)Years Old' ❑ Disposal Field Reuse Expansion,Required(50%of existing system) <br /> system) <br /> Inspection Required <br /> To be evaluated on a case by case basis based on scoPe of proposed project. <br /> [] CommerciaLSystem: Additional evaluation, improvement,and reporting requirements may be applicable. <br /> Comments: iv t C12 udl� f I owavt ' rst tr <br /> e w ra u i 6� c4 mors <br /> cta Y. uA� r F 4 �A. ^L v' t�5.t-c`tsa... Qi)Ud -..�r. `. <br /> tv <br /> ^aro; w w�> >a� t'S 04' ' -,.. au <br /> Consultati n Service Requtred 4aptic Repair Permit Required ❑Septic Repair Permit May Be ReqLlired Per Building Pe mit Conditions <br /> REVIEWED El <br /> REGISTERED ENy1RONWNTAL HEALTH SPECIALIST Date: <br /> PE Sc RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> �yCODE CASH REMIT ED <br /> �y..� I iol[A` <br /> EH 42-021 8/25/2009 Application for Temporary Waiver to Destroy Septic Tank <br />