Laserfiche WebLink
2 <br /> SAN 10 A Q U I N Environmental Health Department <br /> i4 COUNTY <br /> Greatness grows here. <br /> TEMPORARY WAIVER FRQM REQUIREMENT ToDESTROY ABANDONED SEPTIC TANK <br /> SITE LOCATION: CIT DATE: 8 aJd O <br /> PRO ERN OWNER N E: ✓ APN: 9 f O 0 <br /> PROPE N R AILI /tD S: <br /> CITY/ TATE/ZIP: PHO E: -- <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 dest?d '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 unde stand that a septic repair permit may be required prior to the final occupancy of the <br /> rebuilt/replaced structur I erstand that I will esponsible for all EHD enforcement costs should I fail to comply with these' <br /> conditions for the se c to e. <br /> CERTIFIED BY: <br /> PR TY O&EfR SIGNATURE i DATE <br /> FOR EHD USE ONLY <br /> Septic S stem Hi o /Permit Surnmary <br /> Permit#: 90Date: _ U Xpriginal Installation[]Repair❑Replacement❑Addition <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other. <br /> Permit#: Date: ❑Repair❑Replacement❑Addition❑Other <br /> Reuse Conditions <br /> ❑ AGE OF RESIDENTIAL SYSTEM: <br /> I-EssTHANFive 5 Years Old ❑ Re-Connection Inspection Required <br /> ❑ AGE OF RESIDENTIAL SYSTEM: ❑ History of Failures-Additional Disposal Field Installation Required (see Comments) <br /> BETWEEN Five(5)and Ten(10)Years Old ❑ Condition of System Evaluation/Inspection Required <br /> ❑ Re-Connection Inspection Required <br /> ❑ History of Failures-Additional Disposal Field Installation Required (See Comments) <br /> AGE OF RESIDENTIAL SYSTEM: MAI Condition of System Inspection Required <br /> Over Ten(10)Years Old Disposal Field Reuse Expansion Required (50% of exi " <br /> Morn <br /> Re-Connection Inspection Required <br /> • ❑ Commercial System: To be evaluated on a case by case basis based on scope of pm, r ctt.. <br /> Additional evaluation, improvement, and reporting requirements r't able. <br /> Comments: e �GrLQ W1t✓I buddWA ac%/1 sS ? f 7 oZ Q A ve PECNMENTAL <br /> ICES <br /> Y- <br /> consultation Service Required ❑Septic Repair Permit Required Septic Repair Permit May Be Required Per Building Permit Conditions <br /> REVIEWED BY: e_ li L/ J(D <br /> REGISTERED ENVIRONMENTAL HEALTH SPECIALIST Date: <br /> PE SC RECEIVED BY CHECK#/ AMOUNT DATE SERVICE REQUEST# INVOICE# PERMIT ID# <br /> CODE CASH REMITTED <br /> ya 41 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sicehd.com <br /> EH 42-027 82812018 Application for Temporary Waiver to Destroy Septic Tank <br /> i <br />