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SAN-MAQUIN <br />COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: �� G;, j,Vv1�, N (1 r CITY: DATE: <br />I fl: -c <br />PROPERTY OWNER NAME: y�y�— APN: <br />�� � ►� s j li' I � �� Ssoa 0 <br />PROPERTY OWNER M NG AD E <br />»3z) <br />CITY/STATE/ZIP: S�v PHONE: <br />Intent to Rebuild/R place Statement <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 ain e ove noted time period, the septic tank <br />A"Vi <br />will be considered abandoned and I will be req t JU c s permit and inspection from EHD at that <br />time. <br />Reuse Conditions Statement <br />I understand and acknowledge that I )P!9`Sa_flsfT1N condi k for reuse of the septic system for the rebuilt/replaced structure, <br />as indicated below. I also understa d tha tic r p r rmi may be required prior to the final occupancy of the <br />rebuilt/replaced struct un rs nd at ilk be r p i II EHD enforcement costs should I fail to comply with these <br />conditions for the se tic sy r use. <br />CERTIFIED BY: <br />PROPER# OVAER SI TORE DATE % <br />FOR EHD USE ONLY <br />Septic S stem Histo /Permit mary <br />Permit #: (_OO.i Z)L13 <br />Date: <br />q ,y0 /9 <br />tgOriginal Installation ❑Repair ❑Replacement ❑Addition <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Reuse Conditions <br />AGE OF RESIDENTIAL SYSTEM: <br />Re -Connection Inspection Required <br />LESS THAN Five 5) Years Old <br />n History of Failures -Additional Disposal Field Installation Required (See Comments) <br />AGE OF RESIDENTIAL SYSTEM: <br />Condition of System Evaluation/Inspection Required <br />BETWEEN Five (5) and Ten (10) Years Old <br />Re -Connection Inspection Required <br />❑ History of Failures - Additional Disposal Field Installation Required (See Comments) <br />❑ AGE OF RESIDENTIAL SYSTEM: <br />❑ Condition Of System Inspection Required <br />Over Ten (10) Years Old <br />❑ Disposal Field Reuse Expansion Required (50% of existing system) <br />❑ Re -Connection Inspection Required <br />F-1 Commercial System: <br />To be evaluated on a case by case basis based on scope of proposed project. <br />Additional evaluation, improvement, and reporting requirements may be applicable. <br />Comments: Eyi J'r house fl, be- ew%vv �f)J1ne;� p i t Ver/ ! 3G1 9 <br />IAPM J P <br /><<'ow 1- c2 or I ( i <br />Consultation Service Required ❑ Sep is Repair Permit Required X Septic Repair Permit May Be Required Per Building Permit Conditions <br />REVIEWED BY: <br />REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: <br />PE <br />CODE <br />SC <br />RECEIVED BY <br />CHECK#/ <br />CASH <br />AMOUNT <br />REMITTED <br />DATE <br />SERVICE REQUEST # <br />INVOICE # <br />PERMIT ID# <br />S " q33 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s*cehd.com <br />EH 42-0218/28/2019 Application for Temporary Waiver to Destroy Septic Tank <br />