Laserfiche WebLink
10 t`"" - <br />SAN JOAQUIN COUNTY <br />o' <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />kc <br />40 it 600 East Main Street, Stockton, CA 95202-3029 <br />i. <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov,orgi/ehd <br />APPLICATION FOR A TEMPORARY WAIVER <br />FRom REauiREmENT To DEsTRoY AsANooNED SEPTic TANK <br />SITE LOCATION: Cl-, Y: — j <br />, 5 <br />I DATE: <br />PRO1-=P—,y'0WNER NAME, APN: <br />J <br />-PiROP�EFY5�MER VbYi3i. NGA00RESS: <br />PHONE: <br />S's -7 <br />Intent to Rebuild/Repla6e Statement <br />I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed, for <br />demoiitton, 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 />J understand and acknowledge that I must satisfy the conditions for reuse of the septic system for the rebuiltireplaced <br />struct,ire, 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 />. ions for the_ tic system reuse. <br />with these conc-t <br />CERTIFIED BY: <br />PR0MfV'Glomi ER S*NATURP DATE <br />/ - -7 <br />77� 15 i� <br />s_S£,^., <br />01 1 X;00�fnsWbWn ORepair OR"ftmwit OAddiWn <br />Date. GPep* ORepWoywa OAdifton 00dw <br />C41apairORepW6wwt OAdOon 009w <br />rjl�*W OR"Iai6wrierit C -Addition, 0C &r <br />i Date. <br />OR",ak CIS igt4emerd OAdditim 000w <br />........ ........ <br />IC] RConnaction !nsRequired <br />Lm Tii" Five LS) s 04d <br />0 kistiory of Failures - AddRionall0isIx" Field friStOltatM Required Oiae Cone ) <br />AgE OF WAWA%4lLfaf n-/ iC0rKfjfi/W of Systom,'EvaluationittrispecWn Reaired <br />*-7*M Fivo (61,wW Ten (10) Years Old <br />Re-Conneawn lrj� ReWired <br />Hof Faguires - Addibonall Disposal Field trisilallation Required (See Comowift) <br />A4E OF RESMT" SYSTE-W Cored #m of System Inspwm Required <br />Too (ifIlYfos Oid I Disposal FWd Reuse Expansion Required (5(r/* of existitito system) <br />i Re-C�Orl Inspection ROWWad <br />To be evaluated on a case by case ba" based on :ape Of PfOOOS Oct <br />Ad(ftiRomusal uation, imn-y*MM and reporting requkerrif <br />R WT A r1- rN, i E S <br />SeW R"jor perrmt Wy Be RKuvred Per Per1nd40,0V!tM <br />REME WED, BY: 2,— <br />PE AMOUNT <br />RECE(VED BY <br />C R <br />DATE se RvicE ReoueST # <br />INVOiCE # PERM11, ID# <br />coo <br />I <br />App4icatjon for TernW-zr�j Waive, 10 Oastrov Sepu- Tank <br />