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APPLICATION #:AP1322534
STATE OF FLORIDA PERMIT #:56-SF-1813815
r 'r DEPARTMENT OF HEALTH DOCUMENT #:F11151701
�+ ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
'�y s CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:01/09/2018
Opp'` �r FEE PAID:65.00
l V RECEIPT #:56-PID-3463188
APPLICANT: BlueGoose Constructin
AGENT: Bruce Mc Cullers(Reliable Treasure Coast Services)
PROPERTY ADDRESS: 8740 Okeechobee Rd Fort Pierce, FL 34945
LOT: BLOCK:
SUBDIVISION: ID#: 2323-333-0003-000-2
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION SETBACKS
[ J [01] TANK SIZE [1] [2] ( J [27] SURFACE WATER FT
[ J [02] TANK MATERIAL [ ] [28] DITCHES FT
[ ] [031 OUTLET DEVICE [ J (29] PRIVATE WELLS FT
[ ] [04] MULTI-CHAMBERED [ Y / N ] [ ] [30] PUBLIC WELLS FT
[ ] [05] OUTLET FILTER [ ] (31] IRRIGATION WELLS FT
[ J [06] LEGEND 1. 2. [ ] [321 POTABLE WATER FT
[ ] [07] WATERTIGHT [ ] [33] BUILDING FOUNDATIONS FT
[ ] [08] LEVEL [ ] [34] PROPERTY LINES FT
[ ] [09] DEPTH TO LID [ ] [35] OTHER FT
DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM
[ J [10] AREA [1] [2] SQFT [ ] [36] DRAINFIELD COVER
[ J [11] DISTRIBUTION BOX HEADER [ ] (37] SHOULDERS
[ ] [121 NUMBER OF DRAINLINES 1. 2. ( ] [38] SLOPES
[ ] [13] DRAINLINE SEPARATION [ ] [391 STABILIZATION
[ ] [14] DRAINLINE SLOPE
[ ] (15] DEPTH OF COVER ADDITIONAL INFORMATION
[ J [16] ELEVATION [ ABOVE / BELOW ]BM [ J [40] UNOBSTRUCTED AREA
[ ] [17] SYSTEM LOCATION [ J [41] STORMWATER RUNOFF
[ ] [18] DOSING PUMPS [ ] [42] ALARMS
[ ] [19] AGGREGATE SIZE [ J [43] MAINTENANCE AGREEMENT
[ ] [20] AGGREGATE EXCESSIVE FINES [ J [44] BUILDING AREA
[ ] [21] AGGREGATE DEPTH ( ] [45] LOCATION CONFORMS WITH SITE PLAN
FILL / EXCAVATION MATERIAL ( J [46] FINAL SITE GRADING
[ ] [22] FILL AMOUNT [ J [47] CONTRACTOR
[ J [23] FILL TEXTURE [ J (48] OTHER
[ ] [24] EXCAVATION DEPTH ABANDONMENT
[ ] [25] AREA REPLACED [ ] [49] TANK PUMPED 01/09/2018
[ J [261 REPLACEMENT MATERIAL [ ] [50] TANK CRUSHED & FILLEisj /Uy/
dimComments: Comments are on page 2.
S DATE: Q
o 9/2018
CONSTRUCTION [ APPROVED DISAPPROVED ] 'P\v 1$
Environmental Specialist I ianna S May(Florida Depa t R Health
FINAL SYSTEM ( APpROVED / DISAPPROVED ] : f- St. Cie CHD DA / 01
Environmental Specialist ianna S May(Florida Depart ent of Health (a �r I
(Explanation of Violations on following page) P er m� .\e co
DH 4016, 08/09 (Obsoletes all previous editions which may not be used) 5t. vo
Incorporated: 64E-6.003, FAC Page 2 of 3
EH Database v 1.0.1 AP1322534 FID1813615
APPLICATION #:AP1322534
z
STATE OF FLORIDA PERMIT #:56-SF-1813815
x r DEPARTMENT OF HEALTH DOCUMENT #:F11151701
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:01/09/2018
wS FEE PAID:65.00
RECEIPT #:56-PID-3463188
Violation Number Comment
Comments
No violations observed at time of inspection.
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 2 of 3
EH Database v 1.0.1 AP1322534 EID1013015
SEPTIC TANK
ABANDONMENT CERTIFICATION
Permit: #
Address: 'U`-i 0 D k-ze ko i�,eR 1?�)
Ff P�crce FL 3rigg5
DATE THE TANK WAS PUMPED: 9 D
DATE TANK WAS ABANDONED: 9
METHOD OF ABANDONMENT:
CI'us►,\?-d
TANK WAS REMOVED TANK-F�AND FILLED IN PLACE
Company Name
L
Signature of Licensed Contractor
Date i CJ