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SAN JOAQUIN C O U N T Y ------- Environmental Health Department TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: 19730 N. Dustin Rd. CITY: Acampo DATE: 11-4-20 PROPERTY OWNER NAME: Marissa Marcotte APN: 017-120-310-000 PROPERTY OWNER MAILING ADDRESS: 19730 N. Dustin Rd. CITY/STATE/zp: Acampo, CA 95220 PHONE: (925)989-6204 Intent to Rebuild/Replace 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 permit may be required prior to the final occupancy of the rebuilt/replaced structure. I understand that I will he resnonsible for all EHD enforcement costs should I fail to comply with these conditions for the septi%system rel se. CERTIFIED BY: r��il --- - ----- 11-4_20 ---- - PR PERTY OWNER SIGNATURE DATE ---------.ONLY - - Septic S stem Histo /Permit mary Permit #_ < V, ow7W cI S Date: 13 9 — 00riginal Installation ❑Repair ❑Replacement ❑Addition Permit #: Date: ❑Repair []Replacement ❑Addition ❑Other Permit #: Date: ❑Repair [--]Replacement ❑Addition ❑Other ❑Repair ❑Replacement ❑Addition ❑Other ❑Repair ❑Replacement ❑Addition ❑Other Permit #: Date: Permit #: Date: Reuse Conditions ❑ Re -Connection Inspection Required ❑ AGE OF RESIDENTIAL SYSTEM: LESS THAN Five 5 Years Old ❑ History Of Failures - Additional Disposal Field Installation Required (See Comments) ❑ AGE RESIDENTIAL SYSTEM: OF ❑ Condition of System Evaluation/Inspection Required BETWEEN Five (5) and Ten (10) Years Old ❑ Re -Connection Inspection Required ❑ History 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) �( Re -Connection Inspection Required F] 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. 1� Comments: Cone -)1 i 1 1pY1 Of S57e!^/ l: P1 �; >77FCi� (, {� .5e bz /a �t � ),Cl / ] jy �UbMI f{/1 n iif jJ /! }'D - . JIS I' s� See P,jJVP. /�}VIUUr IPG CV! `I%Ie _ LgC-��1 tt1Jn C�ppP}T( 01i� ui7 J9V; ?t7EJ b� 1 6)01Y15 ❑ Consultation Service Required ® Septic Repair Permit Required IN Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE CODE sC RECEIVED BY CHECK#/ CASH AMOUNT REMITTED DATE SERVICE REQUEST# INVOICE # PERMIT ID# 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com