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SAN JOAQUIN --- C OU N T Y --- Greatness grows here. Environmental Health Department TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SFPTIC TANK SITE LOCATION: JM1„ �v _ CiTY: DATE: PROPERTY OWNER NAME:�r / /+ L (� APNC:�92lvCo2 / ! L _ - - -- -1— PROPERTY OWNER MAILING ADDRESS: /7 �v 1, CITY/STATE/ZIP:/�� ^ �f PHONE: W _ (_ c i l 12 Intent to RebuildIRelflace 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 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 mit may be required prior to the final occupancy of the rebuilt/replaced structure. I understand that I will be r sible for all EHD enforcement costs should I fail to comply with these conditions for the Septic Sys re e. �-7 f —; % CERTIFIED BY: `- ,2l PROPERTY OWNER SIGNATURE DATE FOR EHD USE ONLY Septic S stem Histo /Permit Summa Permit #: Date: _ riginal Installation ❑Repair ❑Replacement ❑Addition Permit #: (t OD Date: epair []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: ElRe-Connection Inspection Required LESS THAN Five 5 Years Old ❑ AGE of RESIDENTIAL SYSTEM: ❑ History of Failures - Additional Disposal Field Installation Required (See Comments) ❑ Condition of System Evaluation/Inspection Required BETWEEN Five (5) and Ten (10) Years Old ❑ Re -Connection Inspection Required istory 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) >qme-Connection Inspection Required To be evaluated on a case by case basis based on scope of proposed project. ❑ Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable. Comments: ❑ Consultation Service Required Weptic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST ate: PE CODE SC RECEIVED BY - CHECK#/ CASH AMOUNT REMITTED DATE SERVICE REQUEST # INVOICE # PERMIT ID# ( '21.2 SV 2 1868 E. Hazelton Avenue I Stockton. California 952051 T 209 468-34201 F 209 464-0138 1 www.sicehd.com EH 42-021 812812019 Application for Temporary Waiver to Destroy Septic Tank