Laserfiche WebLink
SAN--JOAQUIN <br />Environmental Health Department <br />COUNTY <br />`c'� r` Greatness grows here. <br />TEMPORARY WAIVER FRQmREQUIREMENT ToDESTROY ABANDONED SEPTIC TANK <br />SITE LOCATION: " CIT DATE: g a pd O <br />PROPERTYOij OWNER N E: r APN:� u O o) <br />I <br />PROPE �Q N R AILING AtD 5: <br />jr <br />CITY/SATE/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 destl�6oy 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 undostand that a septic repair permit may be required prior to the final occupancy of the <br />rebuilt/replaced structurI derstand that I will esponsible for all EHD enforcement costs should I fail to comply with ttx <br />conditions for the se c to e. _ <br />\' <br />CERTIFIED BY: <br />PR TY O R SIGNATURE DATE <br />FOR EHD USE ONLY <br />Septic S stem <br />Hi o /Permit mary <br />Permit #: <br />90 ._ <br />Date: <br />_ U <br />riginal Installation ❑Repair ❑Replacement ❑Addition <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑Other <br />Permit #: <br />Date: <br />❑Repair ❑Replacement ❑Addition ❑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 />F]Re-Connection Inspection Required <br />LESS THAN Five 5)Years Old <br />❑ AGE RESIDENTIAL SYSTEM: <br />❑ History of Failures - Additional Disposal Field Installation Required (See Comments) <br />of <br />❑ Condition of System Evaluation/Inspection Required <br />BETWEEN Five (5) and Ten (10) Years Old <br />❑ Re -Connection Inspection Required <br />❑ History of Failures - Additional Disposal Field Installation Required (see Comments) <br />AGE OF RESIDENTIAL SYSTEM: <br />M Condition of System Inspection Required <br />Over Ten (10) Years Old <br />Disposal Field Reuse Expansion Required (50% of exi <br />Re -Connection Inspection Required <br />❑ Commercial System: <br />To be evaluated on a case by case basis based on scope of pvT r ect. <br />:le. <br />Additional evaluation, improvement, and reporting requirements M �iJ@@ l <br />Comments: >�l t l+ Ff A e CNMENTgI <br />VICES <br />Consultation Service Required ❑ 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 # INVOICE # <br />PERMIT ID# <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.s'cehd.com <br />EH 42-021 8/28/2019 j Application for Temporary Waiver to Destroy Septic Tank <br />i <br />