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:at1'n;r: SANJOAQUIN <br />''►w_ `� COUNTY <br />Greatness grows here. <br />Environmental Health Department <br />TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: ( �JO �+ CITY• h J� ` DATE: <br />Z-3 -Zo2Z <br />PROPERTY OWNER NAME:;� �ST �.w APN: 0,5-3)009) <br />,53) 00 O�rf <br />PROPERTY OWNER MAILING ADDRESS: I30 (Z+ <br />CITY/STATE/ZIP: r p 4 a SZ��PHONE:70 <br />fl d'- G 1 3 S1- 8 <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 systqpn reus <br />CERTIFIED BY: Z-3 -Z-oz Z <br />PROPERTY OWNER SIGNATURE DATE <br />FOR EHD USE ONLY <br />Septic S stem <br />Histo /Permit mary <br />Permit #: <br />g`) - ) 9 35 <br />Date: <br />J? l 13 _ S>tv <br />Original Installation ❑Repair ❑Replacement ❑Addition <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: <br />Date: <br />El Repair ❑Replacement ❑Addition El 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 MR <br />LESS THAN Five 5 Years Old <br />❑ AGE RESIDENTIAL SYSTEM: <br />❑ History Of Failures - Additional Disposal Field Installatlo�Egg0 Jd2@20 Comments) <br />OF <br />❑ Condition of System Evaluation/Inspection Required <br />BETWEEN Five (5) and Ten (10) Years Old <br />❑ Re -Connection Inspection Required ENVIRONMENTAL HEALTH <br />F-1Historyof Failures - Additional Disposal Field Installatig ee omments) <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 />F-1 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: CoyOillar, bF s1,5 -em ins er;}(0n in pilptlr, 1Ohl a sc. tic ;t6(ess)Poe. � <br />fiheY conn rba)1s �F mei, <br />X Consultation Service Required ,K Septic Repair Permit Required Septic Repair Permit May Be Required Per Building Permit Conditions <br />REVIEWED BY: <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 />L13613 <br />no- ;aCo <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sdcehd.com <br />EH 42-0218/28/2019 Application for Temporary Waiver to Destroy Septic Tank <br />