HomeMy WebLinkAboutHealth Department Septic Approval STATE OF FLORIDA PERMIT # S�o'Sl.17 2 S7
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
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APPLICANT:__ .. 't-t ��—r!n'1 t/1C -�,r ... - �- .�r8rs �' k-�-'r t rce VI N�'q
r CONTRACTOR/AGENT .►, t�� 4` ,r�fr� .t" 1 � i ryi hecNet
LOT: RA U BLOCK:. SUBDIV: ID#: {�"t�)"'��'Cmo-ox
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.
EXISTING,TANK INFORMATION
[ ] GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL:!A►'YX'+ �'✓ BAFFLED: [YA j
[ } GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL: BAFFLED: [Y/N
[ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL:
f j GALLONS DOSING TANK LEGEND: MATERIAL: # PUMPS: [ j
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ONc�-J J��, By bcf' i , HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS/FILLING/LEGEND ' ] , ARE FREE OF OBSERVABLE
CTS OR AND HAVE A [ SOLIDS DEFLECTION DEVICE/OUTLET FILTER DEVICE j INSTALLED.
S TORE F ttgOSED CONTRACTOR BUSINESS NAME DATE
EXISTING DRAINFIELD INFORMATION
f
SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES { J DIMENSIONS: I5 X l!
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
TYPE OF SYSTEM: [jQ STANDARD { ] FILLED [ ] MOUND
CONFIGURATION: [ ] TRENCH [/sQ BED { j
DESIGN: [ j HEADER [ j D-BOX GRAVITY SYSTEM [ ] ;DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE INCHES [ABOVE/ FLOW'
SYSTEM FAILURE AND REPAIR INFORMATION
[ ] SYSTEM INSTALLATION DATE TYPE OF WASTE [ j DOMESTIC [ } COMMERCIAL
( j GPD ESTIMATED SEWAGE FLOW BASED ON [ } METERED WATER [ j TABLE 1, 64E-6, FAC
SITE [ ] DRAINAGE STRUCTURES [ j POOL [ j PATIO /'DECK [; j PARKING
CONDITIONS: [ } SLOPING PROPERTY [ j
NATURE,OF { ] HYDRAULIC OVERLOAD [ j SOILS [ ] MAINTENANCE [ j SYSTEM DAMAGE
FAILURE: [ } DRAINAGE / RUN OFF [ j ROOTS j ] WATER TABLE [° j
FAILURE [ j SEWAGE ON GROUND [ j TANK [ ] D BOX/HEADER [ } DRAINFIELD
SYMPTOM: [ ] PLUMBING BACKUP [ ] {
REMARKS/ADDITIONAL CRITERIA
SUBMITTED BY: TITLE/LICENSE t3 fl DATE:
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DH 4015 08/09 (Obsoletes
previous editions which may not be used) 3
Incorporated 64E-5.001, FAC Page 4 of 4 s
3
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STATE OF FLORIDA PERMIT N0. 'S/-, 172
DEPARTMENT OF HEALTH
:DATE PAID:
� ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:' ��
RECEIPT
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APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ ] New System [ ], Existing System [ ] Holding.Tank, [ ] Innovative
[ ] Repair [ f Abandonment [ ] Temporary [ ]
APPLICANT: ClCtAlk &cAeei%S r� �0* erCt?' 3�4qLrj
t 1 f� I
AGENT: A-t 100114 fc-lcr (LX&05 L\nL` Rte' Recker � TELEPHONE: �a LI&k• 000 k-
MAILING ADDRESS: �',.� 1) J �,,VV, LA,1 . I l(?('1' r i 'j�1 t`1�
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 GRANDFATBER PROVISIONS.
PROPERTY INFORMATION
LOT: BLOCK: SUBDIVISION: PLATTED:
PROPERTY ID #: V `1LV�` -� 't ZONING: I/M OR EQUIVALENT: [ Y/N ]
PROPERTY SIZE: �. (6 ACRES WATER SUPPLY: [JC] PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD
I
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y6 ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS:
DIRECTIONS TO PROPERTY:
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
Sin51e- W%--V M� ya
2 Vlie, V n 1
3
4
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE: - � DATE:1�
DE 4015, 08/09 (Obsoletes previous editions which may not be used),
Incorporated 64E-6.001, FAC Page 1 of 4
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St. Lucie County Health Department
Zr-' b 5150 NW Milner Dr Port Saint Lucie, FL 34983
HEALTH
PAYING—OW- PERMIT#:56-SF-1725907 BILL Doc#56-BID-331$217 " CONSTRUCTION APPLICATION#:API 266863
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:
it
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
`'- PERMIT #:66-SF-1726907
-' APPLICATION #:AP 1266$63
u STATE OF FLORIDA
DEPARTMENT OF HEALTHDATE PAID:
r' `tar ONSITE SEWAGE TREATMENT AND DISPOSAL, SYSTEM FEE PAID:
�CONSTRLJ_CTION_PERMIT
RECEIPT #: .....__,_
y °Dvie DOCUMENT #:PR1041798
-----—CONSTRUc-LION PERMI-T-FORS--.-OS-TDS-Abandonment------.--.----_._ --------- -----
APPLICANT: (druil Services Inc)
PROPERTY ADDRESS: 1937 N Old Dixie Hwy Fort Pierce, FI.34946
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. 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 ] GALLONS / GPD Existinq ST to be abandonded CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ ] SQUARE FEET SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] '
I CONFIGURATION: [ ] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ][ I ] [ABOVE/BELOW]BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [ J ] [ABOVE/BELOW]BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ ] INCHES
Have the tank abandoned in accordance with the following procedures:(a)The tank shall be pumped out(b)The bottom
O of the tank shall be opened or ruptured,or the entire tank collapsed so as to prevent the tank from retaining water,and(c)
T The tank shall be filled with clean sand or other suitable material,and completely covered with soil Have'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:
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 AP1266863 SE-1