HomeMy WebLinkAboutHealth Department Septic Approval STATE OF FLORIDA PERMIT # sfo Sl'�17
s DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
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APPLrcANT._ C�t'�"P '1 �q�
CONTRACTOR/AGENT `
LOT: ��1� BLOCK: SUBDIV: ID t7t�c
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR
OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED. DOCUMENTS, COMPLETE ALL APPLICABLE ITEMS.
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
PM, STING,TANK INFORMATION
[kCE*] GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL:/ 1 ✓ BAFFLED: [YA ]
I 1 GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL: BAFFLED: [Y/N ]
[ j GALLONS GREASE INTERCEPTOR LEGEND: MATERIAE.
[ j GALLONS DOSING TANK LEGEND: MATERIAL: # PUMPS: [ j
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON r�t ! 2 Ir BYW' l,0_r HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS/FILLING/LEGEND j, ARE FREE OF OBSERVABLE
2
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AND HAVE A [ SOLIDS DEFLECTION DEVICE/OUTLET FILTER DEVICE INSTALLED.am &m�mcr_46r Q(yees IL
SIMILTURE YF tAUSSED CONTRACTOR BUSINESS NAME DATE
EXISTING DRAINFIELD INFORMATION ;.
[ SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: I5 X Z
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
TYPE OF SYSTEM: [$:I STANDARD [ ] FILLED [ j MOUND [ j
CONFIGURATION: { j TRENCH [ BED { ]
DESIGN: [ j HEADER [ ] D-BOX pdq GRAVITY SYSTEM [ j �DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE ` 7K4 INCHES [ABOVE/ ELOW
SYSTEM FAILURE AND REPAIR INFORMATION
[ ] SYSTEM INSTALLATION DATE TYPE OF WASTE j ] DOMESTIC; j j COMMERCIAL
[ ] GPD ESTIMATED SEWAGE FLOW BASED ON [ ] METERED WATER [ j TABLE I, 64E-6, FAC
SITE [ j DRAINAGE STRUCTURES [ ] POOL [ ] PATIO /DECK [ ] PARKING
CONDITIONS: [ j SLOPING PROPERTY [ ]
NATURE.OF j ] HYDRAULIC OVERLOAD [ ] SOILS [ ] MAINTENANCE [ ] SYSTEM DAMAGE
FAILURE: [ j DRAINAGE / RUN OFF j j ROOTS j ] WATER TABLE f
FAILURE [ j SEWAGE ON GROUND j j TANK [ ] D BOX/HEADER [ j DRAINFIELD
SYMPTOM: [ ] PLUMBING BACKUP [ j
REMARKS/ADDITIONAL CRITERIA
SUBMITTED BY: TITLE/LICENSE b rl DATE:
9 4015,- 0$/09 (Obsoletes previous editions which may not be used) �
naorporated 64E-6.001, FAC Page 4 of 4
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STATE OF FLORIDA PERMIT NO. J&-56 172 S1�0
^+ f DEPARTMENT OF HEALTH DATE PAID: 7
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE ;PAID: \
- - M1 �.-•- . :::SYSTEM.------ - ._.._.: -:. ..... .. ... . _ _._ . ,._. �,i_RECEIPT_#-:.__.
APPLICATION FOR CONSTRUCTION PERMIT i
APPLICATION FOR:
[ ] New System [ j Existing System [ ] Holding.Tank [ ] Innovative
I ] Repair [Yf Abandonment ` L ]( TTemporary
APPLICANT: \� �U[C� i rL l &UQQI%S fl Q*
AGENT: 00n4w-1cf, k,n% ma-Neker og, TELEPHONE: la LIC-g- orlo
MAILING ADDRESS: �IILI 4�,-F�
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3) (m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER. PROVISIONS.
PROPERTY INFORMATION
LOT: BLOCK: SUBDIVISION: PLATTED:
PROPERTY ID #: y�' �-CiUI C3`l7 �� ZONING: I/M OR EQUIVALENT: [ Y/N j
PROPERTY SIZE: Lj� ACRES WATER SUPPLY: [XI PRIVATE PUBLIC [ ]<--2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS?PER � )
3�81.0065, FS? [ Y6 ] DISTANCE TO SEWER: FT
L,-1.J� 1V
PROPERTY ADDRESS: VIC C iyie " q SGrV 'C"M J'I�-i LI Ira
DIRECTIONS TO PROPERTY:
i
BUILDING INFORMATION [ ] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No.. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
3.
2 . �r �1C�e m.11/ V-.c>jAe,
3
4
[ ] Floor/Equipment Drains [ ] Other (Specify)
I
SIGNATURE: 41� DATE:1�-
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4
i St. Lucie County Health Department
gCn� 5150 NW Milner Dr Port Saint Lucie, FL 34983
HEALTH
"- "" -_----6=S 6 - --- -"" '""":56BID=3'3�821�-
CONSTRUCTION A #:PPLICATIONAP1266863
PAYING ON: PERMIT#:5F-1725907 eaLooc
A
RECEIVED FROM: All Contractor Services AMOUNT PAID: $65.00
PAYMENT FORM: CHECK 4624 PAYMENT'DATE: 12/12/2016
MAIL TO: (Crull Services Inc)
,I
FACILITY NAME :
PROPERTY LOCATION:
1937 N Old Dixie Hwy
Fort Pierce,FL 34946
Lot: Block:
Property ID.: 2403-602-0010-000-4
EXPLANATION or DESCRIPTION: QUANTITY. FEE
134-OSTDS Construction Abandonment Permit and Inspecti 1 $ 50.00
-1 -Surcharge (All) 1 $ 15.00
RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID-3155095
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PERMIT #:$6-$F-1725907
APPLICATION, #:AP 1266863
STATE OF FLORIDA
` .DEPARTMENT OF HEALTH DATE PAID:
is ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE; PAID:
—C ONSTRUCTI.ON._PERMIT,.
{
RECEIPT #:.
'"� DOCUMENT #:PRI 041798
`_'__.'---C0NSTRUCTION-PR304IT FOFt'--- oS-TDSAbandonment._.....--
APPLICANT: (Crull Services Inc)
PROPERTY ADDRESS: 1937 N Old Dixie Hwy Fort Pierce,FL 34946
i
LOT: BLOCK: SUBDIVISION:
PROPERTY ID #: 2403-602-0010-000-4 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER •64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF .TIME. I ANY 'CHANGE IN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS. PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.;
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1,000 1 GALLONS / GPD Existing ST to be abandonded CAPACITY
A [ ] GALLONS j GPD CAPACITY/
N [ 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ IGALLONS @[ IDOSES PER 24 HRS #Pumps [ I
D [ 1 SQUARE FEET SYSTEM
R [ I SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ I TRENCH [ I BED [ I
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED, SYSTEM SITE I if / IIABOVE/BELOW,IBENCBMARK/REFERENCE POINT
E-BOTTOM OF DRAINFIELD TO BE [ I[ J IIABOVE/BELOW]BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: j I INCHES
Have the tank abandoned in accordance with the following procedures:(a)The tank shall be pumped out(b)The bottom
0 of the tank shall be opened or ruptured,or the entire tank collapsed so as to prevent theltank from,retaining water,and(c)
T The tank shall be filled with clean sand or other-suitable material,and completely covered with saiLHave the system
H inspected by the health department after it has been pumped and ruptured but before it is filled with sand and covered.
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SPECIFICATIONS BY: JAMIE L DI FRANCESCO TITLE:
i
APPROVED BY: TITLE: Environmental Specialist II St Lucie CHD
Brian Ingram
DATE ISSUED: 12/13/2016 EXPIRATION DATE: 03/13/2017
DH 4016, 08/09 (obsoletes all previous editions which may not be used),
Incorporated: 64E-6.004, FAC Page 1 of 3
v 1.1.4 rAP1266863 SE-1
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Planning&Development Services ASBESTOS NOTICE
Building&Code Regulation Division
2300 Virginia Avenue
Fort Pierce,FL. 34982
Phone:(772)462-2172 Fax:(772)462-6443 ;,
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Asbestos Notice to Contractor
February 02, 2017
L E B DEMOLITION & CONSULTING CONTRACTORS INC
RANDLE L BECKFORD
7 HARBOR ISLE DR E 204
FORT PIERCE, FL 34949
RE: Building Permit Number 1702-0045
i
It is your responsibility to comply with the provisions of Section 469.003, Florida Statutes and to notify the Department
of Environmental Protection of any intentions to remove asbestos when applicable in accordance with state and federal
law.
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ignature
Date
2/2/2017 11:19:49 AM