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SAN J 0 A Q U I N Environmental Health Department COUNTY %recJtR ss q;ows ;Iere. TFMPnPARV WAtvr:c rel,—o-.,;;..,r.....�_�r,______. - - - -- - — - - — - — — r - r rImPWIl.lu IVCD OCr I IG I ANK SITE LOCATION: a ('/ 6y7CITY: DATE: c,�r�is5�'s S ,t--Z'7—ZZ PROPERTY OWNER NAME: r APN: 4' 7 --)CJ,', ?e7 7 -16-0— 3? 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 �reCERTIFIED BY: Z% —PROE DATE FOR EHD USE ONLY Septic S stem Histo /Permit Summa Permit#: ��t7C�53h `f vZ Date: �s / /4,7) ❑Original Installation ❑ Repair WReplacement ❑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: LEss THAN Five 5 Years Old j'0 Re -Connection Inspection Required ❑ AGE OF RESIDENTIAL SYSTEM: - w_ E] History of Failures - Additional Disposal Field Installation Required (See Comments) BETWEEN Five (5) and Ten (10) Years Old ❑ Condition of System Evaluation/Inspection Required Q 7'"�� ❑ Re -Connection Inspection Required ❑ History of Failures - Additional Disposal Field Installa�n�j9dd,t ❑ AGE OF RESIDENTIAL SYSTEM: ❑ Condition Of System Inspection Required pFRMIT/SERVICES Over Ten (10) Years Old ❑ Disposal Field Reuse Expansion Required (50% of existing system) ❑ Re -Connection Inspection Required F1 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: F -U Y) re 4, cC)'11P21 Consultation Service Required ❑ Septic Repair Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: mss-- — 1i- 1i ;2'� • REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: PE CODE SC RECEIVED BY CHECK#/ CASH AMOUNT REMITTED DATE SERVICE REQUEST # INVOICE # PERMIT ID# LldI,, 2 5Q,00Ig13 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sicehd.com EH 42-021 132a/2019 Application ler Temporary Waiver to Destroy Septic Tank