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SHARON <br />COUNT Y <br />',q "" Grc-;tness grows here. <br />Environmental Health Department <br />TEMPORARY WAIVER FROM REQUIREMENT To DESTROY ARANnONFn SEPTIC TANK <br />SITE LOCATION:3 o CITY: Q.r�O� <br />DATE: J u <br />PROPERTY OWNER NAME: ,y. (f� <br />21- - --? <br />PROPERTY OWNER MAILING ADDRESS: <br />CITY/STATE/ZIP: 4fX PHONE: <br />Intent to Rebuild/Replace 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 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 that a septic repair permit may be required prior to the final occupancy of the <br />rebuilt/replaced structure. I understand that I will be responsible for all EHD enforcement costs should I fail to comply with these <br />conditions for the septic system se. <br />CERTIFIED BY: _ 2 Z/ <br />PROPERTr6WNER SI A E DATE <br />FOR EHD USE ONLY <br />Septic System History/Permit Summary <br />Permit #: Date: ❑Original Installation ❑Repair []Replacement ❑Addition <br />Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: Date: ❑Repair []Replacement ❑Addition El Other <br />Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other <br />Reuse Conditions <br />❑ AGE OF RESIDENTIAL SYSTEM: <br />F-1Re-Connection Inspection Required <br />LESS THAN Five 5 Years Old <br />❑ AGE RESIDENTIAL SYSTEM: <br />❑ History of Failures -Additional Disposal Field Installation Required (See Comments) <br />OF <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 />F1 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 />` <br />Comments: N//v 10 t • .- P,. c �..�dv�� ctJ� �v- ' <br />A/e,,,COaI1L GS 17 G 6 t t*: <br />❑ Consultation Service Required tic Rep Permit Required eptic Repair Permit May Be Required Per Building Permit Conditions <br />REVIEWED BY: <br />REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: <br />PE SC <br />CODE <br />RECEIVED BY <br />CHECK#/ <br />CASH <br />AMOUNT <br />REMITTED <br />DATE <br />SERVICE REQUEST # <br />INVOICE # <br />PERMIT ID# <br />�z0/7 <br />- <br />Z� <br />Sagrs% lv <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.s6cehd.com <br />EH 42-021 8/2812019 Application for Temporary Waiver to Destroy Septic Tank <br />