SR0083502 - Laserfiche WebLink

Home Browse Search

°` - - SANAOAQUINrj�-Ciivhfy=tal Health Department COUNTY APR 0 5 2021 c��,F6Pas Greatness grows here. -� 'ENVIRONMENTAL HEALTH TEMPORARY WAIVER )� FROMWFZ6MPI'r Wr*STROYABANDONED SEPTIC TANK SITE LOCATION: 4ybG1g ) K Cko Ift U CITY: l YGG C19 DATE: PROPERTY OWNER NAIUIE: 1 Van 1ci de r APN: PROPERTY OWNER MAILING ADDRESS: 86q8 VV_ �hV l k, Rl. ✓ l7 CITY/STATE/ZIP: 7-rnC I n y) 01530 PHONE: _Q/L1 _ / Intent to Rebuild/Replace Statement _I (J 7 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 undp4tand that I will be re ponsible for all EHD enforcement costs should I fail to comply with these conditions for the septic sys m r �_ CERTIFIED BY: _ PROPERTY O AER SIGNATURE DATE FOR EHD USE ONLY Septic S stem Histo /Permit mary Permit#: 5)�00d7 X35 Date: 1 / O j [,Original Installation❑Repair❑Replacement❑Addition Permit#: Date: ❑Repair❑Replacement❑Addition❑Other Permit#: Date: ❑Repair❑Replacement❑Addition❑Other Permit#: Date: El Repair El Replacement❑Addition El Other Permit#: Date: [I Repair EJ Replacement❑Addition El Other Reuse Conditions ❑ AGE OF RESIDENTIAL SYSTEM: LESS THAN Five 5 Years Old ElRe-ConnectionInspection Required AGE OF RESIDENTIAL SYSTEM: ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) BETWEEN Five(5)and Ten(10)Years Old Condition of System Evaluation/Inspection Required 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 To be evaluated on a case by case basis based on scope of proposed project. F-1 Commercial System: Additional evaluation, improvement, and reporting requirements may be applicable. Comments: »G(I}joyi o� 5 5tevl Yel ,Ireof In ),J Y1,tin b c, se 1Ic JI21o ❑ Consultation Service Required ❑ Septic Repair Permit Required Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: _ Z- REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# CODE CASH REMITTED Ia(-�:,3 1 5 -15 1868 E. Hazelton Avenue I Stockton, California 95205 J T 209 468-3420 1 F 209 464-0138 1 www.s*cehd.com EH 42-021 8/28/2019 Application for Temporary Waiver to Destroy Septic Tank