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SAN J QA Q U i N Environmental Health ®epartrnejy --COU NTY-- - GrL;Ttr►ess grctti> l;e TEMPORARY WAI\/Fp G'onnnDc 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com EH t2 -G21 Enc( -%GS? Apph ation for Ternp .ar; Waiver to Destroy Seoft Tari; - - - ---- - --�-•• •-•••--•. ... .+�., nv r nonlvuVlVCU JCY Ill, I ANK SITE LOCATION: ��, CITY: DATE: PROPERTY OWNER NAME: AP PROPERTY OWNER MAILING ADDRESS: ---_ - - - — -- - — --------- -- CITY/STATE/ZIP: - -- — - - 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 th t I will be responsible for all EHD enforcement costs should I fail to comply with these conditions for the s reuse CERTIFIED BY: !PRl IGNATURE DATE FOR EHD USE ONLY Septic System Histo /Permit Summa Permit#: �� 3�' fu7 Date: ❑Original Installation ❑RepairWReplacement❑Addition Permit #: Date: ❑Repair ❑Replacement ❑Addition ❑Other Permit #' Date: ❑Repair ❑Replacement ❑Addition ❑Other Permit #: _ Date: []Repair ❑Replacement ❑Addition ❑Other Permit #: i Date: – — []Repair ❑Addition ❑Other Reuse Conditions — -- AGEOFRESIDENTIALSYSTEM: Re -Connection Inspection Required LESS THAN Five 5 Years Old ❑ AGE OF RESIDENTIAL SYSTEM: ❑ History of Failures - Additional Disposal Field Installation Required (See Comments) BETWEEN Five (5) and Ten (10) Years Old El Condition of System Evaluation/Inspection Required 7 202? ❑ Re -Connection Inspection Required ❑ AGE RESIDENTIAL ❑ History of Failures - Additional Disposal Field Install%r�j�tpg��j OF SYSTEM: ❑ Condition Of System Inspection Required PERMIT/SERVICES 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 Fv fl rfE'C,,cf'Tf"4 of seOjc _,w4(")r ar <.kc> fR L/ ? v Consultation Service Required ❑ Septic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: t; .�:7_ 1� Zi REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Dale: PE CODE SC RECEIVED BY CHECK#/ AMOUNT CASH REMITTED ATE SERVICE REQUEST # INVOICE # PERMIT ID# 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com EH t2 -G21 Enc( -%GS? Apph ation for Ternp .ar; Waiver to Destroy Seoft Tari;