SR0085122 - Laserfiche WebLink

Home Browse Search

V Q N J oQ Q U I N Environmental Health Department COUNTY Greatness grows here. TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK 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 JIIC LVI.HIIUN: ,5 N. t �76jLC_ CrrY DATE: PROPERTY OWNER NAME: APN: , PROPERTY OWNER MAILING ADDRESS:) D CITY/STATE/ZIP: p LIUQAJ CA _25,236 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 understa a I will be responsible for all EHD enforcement costs should I fail to comply with these c syst m reu e., conditions for the sKRERTY CERTIFIED BY: -% OWNS SIC+ RE DkrE FOR EHD USE ONLY Septic S stem Histo /Permit Summa Permit #:D Z ate: Date: q -1l .- l 6 ❑Original Installation epair ❑Replacement ❑Addition Permit #: r2— Date: _ -- ❑Repair []Replacement ❑Addition ❑Other J Permit #: Date: ❑Repair []Replacement ❑Addition ❑Other Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Reuse Conditions ❑ AGE OF RESIDENTIAL SYSTEM: LESS THAN Five 5 Years Old ❑ Re -Connection Inspection Required ❑ AGE OF RESIDENTIAL SYSTEM: El History of Fai ures - Additional Disposal Field Installation Required (See Comments) BETWEEN Five (TI and Ten (10) Years Old El Condition of System Evaluation/Inspection Required ❑ Re -Connection Inspection Required AGE OF RESIDENTIAL SYSTEM: History of Failures - Additional Disposal Field Installation Required (See comments) Condition System Inspection of Required 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: �;;D p S UM ❑ Consultation Service Required Septic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY Z_ Z_ REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE CODE SCRECEIVED BY CHECK#/ CASH AMOUNT REMITTED DATE SERVICE REQUEST # INVOICE # PERMIT ID# 1.1a63 X C8 0 q22 _81- 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