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SAN 10AQUIN <br />COUNTY <br />I'r•.� i111r55 U'r0;^'c iir-f"�. <br />Environmental Health Department <br />TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: 15q N, t r1Gt:,7��� ��� CIT YDATE: <br />n�C <br />PROPERTY OWNER NAME: 1� <br />ApN:a _ <br />PROPERTY OWNER MAILING ADDRESS:! ` <br />CITY/STATE/ZIP:LAA. 1 GSA q � PHONE: � fot 1557 <br />G{ V0 <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 understana I will be responsible for all EHD enforcement costs should I fail to comply with these <br />conditions for the se tic sm reu e. <br />yst <br />CERTIFIED BY: i \ (-/7-_� <br />RO ERTY OWNN IGN RE D E <br />FOR EHD USE ONLY <br />Septic S stem Histo /Permit <br />mary <br />Permit #: <br />Date: <br />q-11— <br />❑Original Installation Ekepair ❑Replacement ❑Addition <br />Permit #: <br />r <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other (iq ASN <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 />❑ AGE OF RESIDENTIAL SYSTEM: <br />❑ History of Failures -Additional Disposal Field Installation Required (see Comments) <br />❑ Condition of System Evaluation/Inspection Required <br />BETWEEN Five (5) and Ten (10) Years Old <br />❑ Re -Connection Inspection Required <br />AGE OF RESIDENTIAL SYSTEM: <br />History of Failures - Additional Disposal Field Installation Required (see comments) <br />Condition Of System Inspection Required <br />Over Ten (10) Years Old <br />Disposal Field Reuse Expansion Required (50% of existing system) <br />` <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 />Comments: Ej`� p I S <br />vlN64) <br />❑ Consultation Service Required &Septic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions <br />REVIEWED BY: Z_ <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 />L�a63 <br />0 �22 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com <br />EH 42-021 8128/2019 <br />Application for Temporary Waiver to Destroy Septic Tank <br />