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SAN J O A Q U I N Environmental Health Department COUNTY eatness grows i SITE LOCATION: I CITY: V _ DATE: I O C7 PROPERTY OWNER NAME: til , � I� APN: ,_Z -07 PROPERTY OWNER MAILING ADDRESS: CITY/STATE/ZIP: PHONE: A '/ Intent to Rebuild/Replace Statement 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 demolif?-E C E 0 S;�/'/'E D 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 peWarllnst�aation from EHD at that time. [LUUII�� Reuse Conditions Statement ENVIRON M NT I understand and acknowledge that I must satisfy the conditions for reuse of the septi iltlre laced structure, as indicated below. I also understand that a septic repair permit may be required priior two t�e ina7&&d 4of�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 system reuse. CERTIFIED BY: z,I f � I PROPERTY OWNER SIGN RE DATE FOR EHD USE ONLY Septic S stem Histo /Permit Summar Permit#: Z — o Date: S (� L- ❑Original Installation DdRepair❑Replacement❑Addition Permit#: o Z yyG Date: b 0 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: ❑ Re-Connection Inspection Required LESS THAN Five(5)Years Old ❑ 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 ❑ Re-Connection Inspection Required ❑ 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 existing system) Re-Connection Inspection Required To be evaluated on a case by case basis based on scope of proposed project. F-1 Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable. Comments: ❑ Consultation Service Rired El Septic air Pe mit Required Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST te: PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# CODE CASH REMITJED 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com EH 42-021 4/24/2012 Application for Temporary Waiver to Destroy Septic Tank