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Envirental Health Department COUNTY TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION : CT >< CITY: V� DATE : PROPERTY Ove R / V PROPERTY OWNER APN: I 0 ' 7rplow . �L� L G% r7 - `>7- CITY/STATE/ZIP : � } PHONE: C� y. Intent to Rebuild/Replace Statement _7 G� �, 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 the septic "s s �_.,_~ use . CERTIFIED BY: v1 / pip, PROPERTY OWNER IGNATUI / FOR EHD USE ONLY DATE Se tic S stem Histo /Permit Summa Permit #: St-14 � � Date : 1 � i ❑ Original Installation XRepaii Replacement ❑Addition Permit #: Date : ❑ Repair [] Replacement ❑Addition ❑ Other Permit #: Date : ❑ Repair ❑ Replacement ❑Addition ❑ Other Permit #: Date : ❑ Repair ❑ Replacement ❑Addition ❑ Other Permit #: Date : ❑ Repair ❑ Replacement ❑Addition ❑ Other Reuse Conditions ❑ AGE OF RESIDENTIAL SYSTEM : LESS THAN Five (5) Years Old ❑ Re-Connection Inspection Required ❑ AGE OF RESIDENTIAL SYSTEM : ❑ History of Failures - Additional Disposal Field Installation Required (See Comments) BETWEEN Five (5) and Ten (10) Years Old ❑ Condition of System Evaluation/Inspection Required ElRep.-ConnectionInspection Required q ❑N History of Failures - Additional Disposal Field Installation Required (See comments) AGE OF RESIDENTIAL SYSTEM: Condition of System Inspection Required Over Ten (10) Years Old Disposal Field Reuse Expansion Required ( 50 % of existingsystem ) Re-Connection Inspection Required y ) ❑ Commercial System : To be evaluated on a case by case basis based on scope of proposed project. Comments : Additional evaluation , improvement, and reporting requirements may be applicable . C - � s J. Qrs , • % y ,�: � 5 % ze lYill" zipIi6jein "Il5 row, Consultation Service Required Septic Repair Permit Required Septic Repair Permit May Be Required Per Building Permit Conditions n(EVIEWED BY : � ? e � '� liiiiiii MEN REGISTERED ENVIRONMENTAL HEALTH SPECIALIST PE I CHECK#/ ate: SC RECEIVED BY AMOUNT CODE CASH REMITTED DATE SERVICE REQUEST # INVOICE # PERMIT ID# 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 1 F 209 464-0138 1 www. sicehd . com EH 42-021 8/2812019 Application for Temporary Waiver to Destrov Septic Tank