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E SAN 0 A 0 U I N C O U N TY----- c�tT P Greatness grows here. Environmental Health Department TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION:1-1 �? I mot oSC'P. CITY: i�� k j DATE: PROPERTY OW AME: APN: PROPERTY OWNER MAILI I&ADDRESS: / / `7 CI E I: )� - , I PHONE: � 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 be responsible for all EHD enforcement costs should I fail to comply with these conditions for the septi Ste se. IZI) CERTIFIED BY: °J Z Z PRO ERTY OWNER SI NATURE DATE FOR EHD USE ONLY Septic S stem Histo /Permit mary Permit #: d OFC% Date: iJ /Y/ 00riginal Installation ❑Repair ❑Replacement ❑Addition Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Reuse Conditions ❑ AGE OF RESIDENTIAL SYSTEM: F-1Re-Connection Inspection Required LESS THAN Five 5 Years Old na g P, tg WS ❑ AGE OF RESIDENTIAL SYSTEM: ❑ History Of Failures - Additional Disposal Field Installation e (See Comments) ❑ Condition System Evaluation/Inspection Required 2 2020 BETWEEN Five (5) and Ten (10) Years Old of SEP 2 ❑ Re -Connection Inspection Required AGE OF RESIDENTIAL SYSTEM: History of Failures - Additional Disposal Field Installation Condition of System Inspection Required PERM T Over Ten (10) Years Old Disposal Field Reuse Expansion Required (50% of existing system) Re -Connection Inspection Required ❑ 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. Comments: Pel r41 } 3`d JFG lss,,,e l }t, r3.7d il r., oscm s 11 J0 ;C/1 he; L'ee;n C.;3F � r� ✓ o!�•e c%l i n ;n! 1� � � a ri S' ' l;c ( �,;t ;, 1, Consultation Service Required ® Septic Repair Permit Required Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: =T— /--- Z -- REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE CODE SC RECEIVE BY CHECK#/ CASH AMOUNT REMITTED DATE SERVICE REQUEST # INVOICE # PERMIT ID# Idt.s 21.10 Qc)is-zvzol Y 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.socehd.com EH 42-021 8/2812019 Application for Temporary Waiver to Destroy Septic Tank