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J A N J 0 A Q U I N Environmental Health Department COUNTY Greatness grows here. TEMPORARY WAIVER FROM REQUIREMENT TO DESTROY ABANDONED SEPTIC TANK SITE LOCATION: Z I��(+ i CITY: C DATE: i I ZoZ PROPERTY OWNER NAME: D D Y C) �I TD t b rt qpN:©�S d o Z PROPERTY OWNER MAILING ADDRESS: f ►"l A4 CITY/STATE/ZIP: ^ am-J20 ,^^ O C jd �Z r�� PHONE: 1..vV."/�- l/� �lJ 7.0 r 3 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 Sept*Tum CERTIFIED BY: MCC* PROPERTY OWNER SIGNATURE DATE FOR EHD USE ONLY Septic S stem Histo /Permit Su rnarV vcfpkir tan /ll, L Permit#: � J J Date: -1 l1/34 riginal 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: LESS THAN Five(5)Years Old ❑ Re-Connection Inspection Required ❑ AGE of RESIDENTIAL SYSTEM: ❑ History of Failures -Additional Disposal Field Installation Required (see Comments) BETWEEN Five(5)and Ten(10)Years Old ❑ Condition of System Evaluation/Inspection Required ❑ Re-Connection Inspection Required 11 Istory of Failures -Additional Disposal Field Installation Required (See Comments) AGE OF RESIDENTIAL SYSTEM: �ondition of System Inspection Required Over Ten(10)Years Old �isposal Field Reuse Expansion Required (50% of existing system) 6RR•e-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: O q#- In ;S-�0r l �D r ❑ Consultation Service Required Septic Rep it Permit Required ❑ Septic Repair Permit May Be Required Per Building Permit Conditions REVIEWED BY: ) !� c�-C7 GISTE VIRO MENT HEALT SPECIALIST Date: PE SC RECEIVED BY CHECK#I V AMOUN DATE SERVICE REQUEST# INVOICE# PERMIT ID# CODF CASH REMITTED ,3121 onsz Lei 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.s4cehd.com EH 42-021 8/28/2019 Application for Temporary Waiver to Destroy Septic Tank