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Environmental Health Department TEMPORARY WAIVER FROM REQUIREMENT T SITE LOCATION:(., ,-..;S--0 CA i be ) )CITY: r,- c.-5(eJOrl ...._.. -, DATE: 5/30/2 i PROPERTY OWNER NAME: . 61 -7.2 APN: /L cm — pooa .$ ----74,-PY---- PROPERTY OWNER MAILING, RESS:X6-e,...r / 9--0 - "? "9,37 6---?(/' ..5.), , 6 a c-y f(3 1 crryisTATEIzip: .4.-_--_; - 6, PHONE: ....5 c----L 1 ,-) _,..,<_ 2';`---.32-(7 .. - Intent to Rebuild/Replace Statement _ I hereby declare that it is my intention to obtain a building permit to rebuild/replape 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 from, Septic Tank Abandonment Statement 3 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 u rstand - -t I will be responsible for all EHD enforcement costs should I fail to comply with these conditions for the septic em rr- . :. CERTIFIED BY: 3 .73 :2, 0?-1 PROPERTY OWNER SIGNATURE DATE FOR EHD USE ONLY Septic System History/Permit Summary Permit #: 73 - los 0 Date: jo /9 q /73 40riginal Installation • Repair • Replacement II Addition Permit #: s g oogl 0 03 Date: /..1 j e OE 4Repair • Replacement II Addition • Other Permit #: Date: ill Repair • Replacement • Addition • Other Permit #: Date: "'Repair IN Replacement 'Addition • Other Permit #: Date: • Repair Replacement • Addition • Other Reuse Conditions AGE OF RESIDENTIAL SYSTENI: LESS THAN Five (5) Years Old Re-Connection Inspection Required AGE OF RESIDENTIAL SYSTEM: BETWEEN Five (5) and Ten (10) Years Old History of Failures - Additional Disposal Field Installation Required (See Comments) Condition of System Evaluation/Inspection Required Re-Connection Inspection Required 04 AGE OF RESIDENTIAL SYSTEM: Over Ten (10) Years Old History of Failures - Additional Disposal Field Installation Required (See Comments) Condition of System Inspection Required I Disposal Field Reuse Expansion Required (50% of existing system) E Re-Connection Inspection Required fl Commercial System: To be evaluated on a case by case basis based on scope of proposed project. Additional evaluatiOn, improvement and reporting requirements may be applicable. , Comments: J 4 4n cer +ip cot }.I Tat ier se p4.1( sys+ern f.e 1., • te 0/ 6-4,plan e ibre a. ,,eppie f") d ed , _ , fet) t cfe . Consultation Service Required Z Septic Repair Permit Required C Septic Repair Permit May Be Required Per Building. Permit Conditions, REVIEWED BY:___--------Z___- REGISTERED ENVIRONMENTAL HEALTH $PECIAL1ST ate: PE CODE SC RECEIVED BY CHECK#i CASH AMOUNT REMITTED DATE SERVICE REQUEST # INVOICE # PERMIT ID# /40.3 /ef U /14 ,c100 '1) 1868 E. Hazelton Avenue I Stockton, California 95205 I T 209 468-3420 I F 209 464-0138 I www.sicehd.com Application for Temporary Waiver to Destroy Septic Tank EH 42-021 8/28/2019