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SANI;JOAQUIN <br />COUNTY <br />SITE LOCATION: <br />PROPERTY <br />lealness <br />NAME: <br />Environmental Health Department <br />TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />?2607 N SOWLES RD CITY: ACAMPO DATE* <br />SON & WENDY HARRIS <br />ADDREss: 22595 N SOWLES <br />mpo, <br />1- <br />007360 <br />PHONE: CELL -(209)-993 4658 <br />Intent to Rebuttd/Replace Statement <br />I hereby declare that it is my intention to obtain a building permit to rebuild/replace the structure being proposed <br />as indicated on the demolition permit application, within three (3) months from the date of demolition and to complete helition, <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 t ptic repair permit may be required prior to the final occupancy of the <br />rebuilt/replaced structur . I u ersta d will be responsible for all EHD enforcement costs should I fail to comply with these <br />conditions for the Sep ' y em r s . <br />CERTIFIED BY: i/ Zo �z0 <br />PROPERTY OWNS I A URE DATE O <br />Permit #: $ R OOO 815 r Date: la � � � S (,Original Installation ❑Repair ❑Replacement ❑Addition <br />Permit #: j /2 0 006,E ��; Date: <br />% /d 6 Repair ❑Replacement I jAddition ❑Other <br />Permit #: Date: <br />❑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 ❑ Re -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 />AGE OF RESIDENTIAL SYSTEM:History of Failures - Additional Disposal Field Installation Required (See comments) <br />i Condition of System Inspection Required <br />Over Ten (10) Years Old Disposal Field Reuse Expansion Required (50% of existing system) <br />Re -Connection Inspection Required <br />❑ Commercial System: <br />Comments: 21 <br />(XI Consultation Service <br />REVIEWED BY: /_ <br />To be evaluated on a case by case basis based on scope of proposed project. <br />Additional evaluation, improvement, and reporting requirement <br />s may be applicable. <br />rCaWt arL'.il%��; Of 9 y/ <br />-__ / f� !o P,l+►Dcr✓Isi�yr y�J rp.> rPC7% S1 �7pm <br />r e4 .A fonl'IBL11IrIC i� .�s,% �i-rtis�a <br />Permit <br />Permit May Be Required Per Building Permit <br />REGISTERED ENVIRONMENTAL HEALTH SPECIALIST <br />PE CHECK#/ AMOUNT <br />CODE SC RECEIVED BY <br />CASH REMITTED DATE SERVICE REQUEST # <br />INVOICE # <br />1868 E. Hazelton Avenue � Stockton, California 95205 (T 209 468-3420 1 F 209 464-0138 � www.sicehd.com <br />EH 42-027 8f28/2079 <br />Application forTwnporary <br />Date: <br />PERMIT ID# <br />Waiver to Destroy Septic `eank <br />