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SAN J OAQ U I N Environmental Health Department <br /> COUNTY------- <br /> Greatness grows her <br /> TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: ,joJ�) �j �U` CITY: 1 DATE: _�_ j ; <br /> PROPERTY OWNER NAME: t� A& <br /> PROPERTY OWNER M LING ARESS: , <br /> Do 1� Tit <br /> CITY/STATE/ZIP: \'06U_ <br /> '_ ' v PHONE: a o� <br /> Intent to Rebuild/Replace Statement l(� <br /> I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed for demolition, <br /> as indicated on the demolition permit application, within three (3) months from the date of demolition, and to complete the <br /> 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 tank <br /> will be considered abandoned and I will be required to destroy the septic system under permit and inspection from EHD at that <br /> 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 structure, <br /> as indicated below. I also understand that a septic repair permit may be required prior to the final occupancy of the <br /> rebuilt/replaced structure. I understand that I will be responsiblefor all EHD enforcement costs should I fail to comply with these <br /> conditions for the septic sy t euse. <br /> CERTIFIED BY: <br /> PROPERTY OW ER GNATURE DATE <br /> FOR EHD USE ONLY <br /> Septic S stem Histo /Permit Summa <br /> Permit#: Q� Date: 717/ Original Installation ❑Repair❑Replacement❑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: ❑Repair[]Replacement❑Addition ❑Other <br /> Reuse Conditions <br /> ❑ AGE OF RESIDENTIAL SYSTEM: <br /> LESS THAN Five(5)Years Old F-1Re-Connection Inspection Required <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: EZ,Condition Of System Inspection Required <br /> Over Ten (10)Years Old isposal Field Reuse Expansion Required (50% of existing system) <br /> Re-Connection Inspection Required <br /> To be evaluated on a case by case basis based on scope of proposed project. <br /> ❑ Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable. <br /> Comments: <br /> Consultation Service R ired Septic Rep i ermit equired ❑ Septic Repair Permit May Be Required Per Building Permit Co9ditiops <br /> REVIEWED BY: <br /> REGISTER NV ONMENTAL HEALTH SPECIALIST I Date: <br /> PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> CODE CASH REMITT <br /> `1 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br /> EH 42-021 8/28/2019 Application for Temporary Waiver to Destroy Septic Tank <br />