HomeMy WebLinkAboutSewageREORDER FROM: APEX BUSINESS FORMS
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE'SEWAGE DISPOSAL SYSTEM FEE PAID
CONSTRUCTION PERMIT .RECEIPT
Authority: Chapter 381, PS & Chapter 1OD-6,. FAC:
CONSTRUCTION PERMIT FOR:
[-�=]New: System [ ] Existing System [ ]. Holding Tank [ j Temporary/Experimental
( ],'Repair [ j Abandonment [ ], Other(Specify).
APPLICANT; t I t lv t..9. t o . i. AGENT: C - a` rt 1 [J
PROPERTY STREET ADDRESS:
LOT: BLOCK: SUBDIVISION:
:PROPERTY ID i/: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER'].
- - [OR TAX ID NUMBER) u
SYSTEM MUST HE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER IOD-6, 'FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE SO DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS,
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS 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', REQUI RE'THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SATURATION FROM ROOF DRAINAGE,
SYSTEM DESIGN AND SPECIFICATIONS ROOF MUST BE GUTTERED PRIQR TO.
€UMkAPPROVAL.
T
(' ](,GALLONS / GPDj, S-EPTIC TA-N1/AEROBIC UNIT CAPACITY `MULTI-CHAMBERED/ZN SERIES:[ ]
A [ ] ['GALLONS / GPD]�""�^"" CAPACITY ff=T CHAMBERED/.IN.SERIES:[ ]
N. [ ] GALLONS GREASE INTERCEPTOR 'CAPACITY [MAXIMUM CAPACITY SINGLE TANK:. 1250 GALLONS]
K [ j GALLONS PER DOSE DOSING TANK. CAPACITY DOSE -RATE [ ], PER 24 HRS NO. OF PUMPS: [ ]
I'.SQUARE. FEET PRI14ARY DRAINFIELD SYSTEM
[ ] SQUARE FEET .SYSTEM
TYPE SYSTEM: �{ .+19 [ ] STANDARD [ ] FILLED ,(.] MOUND [ ]
CONFIGURATION:' tx [ ]{'TRENCH. p[ BED'
'�` .. • .s 1.�a`92`�-��7 ] ):� (i:u�¢7 t;FJ �:Ol L"3 ��;_ >-'++ t ";�.• �K,J
LOCATION OF BENCHMARK:..G St LL zI kif
4FIi _
BOTTOMI,OF DRAINFIELDDTOYBEE[ } 'd„) ]' {i•NCHES/.E-T ]]�-{..A$O.VEt-RFT-OW.] nE.kCHMAHIC/$EEEHEILCF-k.Q,T.J$S
FILL REQUIRED: [1Clj ] INCHES EXCAVATION REQUIRED:'. [H I INCHES
r.
SPECIFICATIONS BY: +. TITLE':
APPROVED BY' `�. `' TITLE "`�4 - - - -,( f CPHU
DATE ISSUED: ERP.IRATION DATE i ,
E) d }a1+
HRS-If Form 4016;. Mar 92 (Obso(eteS previous editions which may not be used) Page 1 of 2
(Stock Number: '5744-001-4016-0)
Al NI n1h1i� IIFPARTMFNT
INS:-R`FCT IONS
PE12:tvi11NUM13$1c:
Pe.-mi[tric i#g.^.nrohc-L'y crFIU.
A.PPLICATTO N. FOR:
Ch. t o typE of Pei MA; if `(}t:,n" sPcei`} typ: is ata.t.k.
,A?PL[CA,IJT:
properly a Mer'e full rare@.
TELhPEONE,:
Telep hu"e number for : PPUCanl er agent,
A('N NT:
Property o"Mer'3 lzgatly authorized repr'ACntatrve.
M AILLN:3. DDRESR.
P.Q. t ox or street mai!ing addrers for applicant or agent.
LOT, PLQCK, Sli4F;.lV l0N
+)r
PROPERTY ID#:
27 Charaet" ID number i'or property. (CNIU way reclaim propi rty atlpe'aiser ID>'t of psc[ion7towDSSip/rangC'¢arcc3 number.)
SY°.Iii;vi DESIGN AND
SPECIFIC'M(3N5.;
'rA15TK
Wn:aria- sgecif zatio�a from Chaptcr IGD-6, PAC.
DRAIN IF LD-:
Wriimum specr+i. ,tioos from Chapter 14D-6, 1%i C.
QT14FIR
otlwr SpeCl/[{aii.7Y; S,. Sbrh &a operoing permit vaquire93Ev u,. 10.E Voluwo fli,.h i61]eb. YkiH.A c? m-GN.M'.
SPCCInICA" fIONE BY:
tinnre of #ndl ,oa; providng +pLcii=cntigaa. If deaf tzal by a rtg+stertd ez:gineer rrnsl i1. sreLe3_
APPRGVI+D Wr
Coarsty Public lieaiih Uaill (CF1E1-) re onnel reV'iewiag and ¢ppmviatg pe6mlt.
DATE ISSURD;
Du`a prrcnit is i*iued by CP11'L'.
tXrIR ;'rl0N'DAT7,.
.)^-, year fm'n d.f., i _',:e„ .f tu... stgm ha; n: t bec,.i in_t,li;:d. perEnita for 6ptem ray>airs hccorte void 90 :Sacs from ike
date
14,
STATE OF FLORIDA
DEPARTMENT OF HEALTHAND REHABILITATIVE SERVICES
.- pNSITE,SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: chapter 381, FS & Chapter IOD-6, PAC
PERMIT F
DATE PAID
FEE PAID
RECEIPT i
APPLICATION FOR:
y
[g] New System'
[ ] Existing System
[ ] Holding Tank.
[ ] Temporary/Experimental
[ } Repair
[ ] Abandonment
[ ] Other(Specify)
APPLICANT: Carol
A. Van Horne
TELEPHONE- 954/971-8048
AGENT:
Lindahl
Browning Ferrari
F RP11strom, Inc
-
MAILING ADDRESS:
2222 Colonial Road,
Suite 201, Fort
Pgerce, Florida 34950
---------------------------------------------------------------------------
TO BE COMPLETED BY APPLICANT OR APPLICANT'S. AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE..
PROPERTY INFORMATION 'IF LOT IS NOT IN A_RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: SUBDIVISION: DATE OF
SUBDIVISION:
-
PROPERTY ID #: [Section/Township/Range/Parcel No. .ZONING•
42-01-134-0003-0105
PROPERTY SIZE:.-' 5_..0 ACRES [Sgft/43560]PROPERTY WATER SUPPLY: PRIVATE. -- PUBLIC
PROPERTY STREET ADDRESS:_ Range Line Road St.�Wcie County, Florida
DIRECTIONS TO PROPERTY: Midway Road West to Glades Cutoff Road, south on -
. i
Glades Cutoff Road to Range'Line Road, south on Range Line Road to site.
BUILDIfid-INFORMATION [ ] RESIDENTIAL
Unit Type of - No. of
.No Establishment Bedrooms
1
4
[ ] GarbageTGrinders/Disposals
[ ] Ultra -low Volume Flush 'Toilets
-,APPLICANT'S SIGNATURE:. \ •µ^w-i(� I/`
[x ] COMMERCIAL
Building #'Persons Business Activity
Area Saft Served or Commercial Only
1�1
la.nnn mate.rip] Stor---
[ ] Spas/Hot Tubs [ ] Floor/Equipment Drains.
[ % )/other (Specify) one bathroom
� ry f.' �
HRS-H, Form 4015, Mar 92 (Obso(etes previous edition�:which may ;note Lsed)
(Stock Number: 5744-001-4015-1), P
DATE: a I (ij 6-1
Page 1 of 3
'i
S.
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION:
PROPERTY ID#:
PROPERTY SIZE:
WATER SUPPLY:
PROPERTY ADDRESS:
DIRECTIONS:
Check type of permit, if'Other' specify type in blank.
Property owner 's full name.
Telephone. number for applicant or agent.
Property owner's legally authorized representative.
P.O. box or sheet, city, state, and zip code malting address for applicant or agent.
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If tot is not in a recorded subdivision, a copy of the lot
legal descript,on or deed must be attached.
Official date of subdivision recorded in county plat books (month/day/year) or date lot originally recorded. Dividing an approved
lot into two or More parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
27 character number for property. (CPHU may require property appraiser ID # or sectionitownship/range/parcel number.
Net usable area of property in acres (square footage divided by 43,560 square feat) exclusive of all paved areas and prepared road
beds within public rights -of way or casements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water, Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in celculatiog lot area.
Check private or public.
Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
Provide detailed instructions to hK or attach an area map showing lot location.
BUILDING INFORIVIATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table 11, Chapter 10D-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
BUILDING AREA: Total square, footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or Polly
screened patios a. decks. Based on outside measurements for each story of structure.
# PERSONS. Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom am
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table 11, Chapter IOD-6, FAC.
FIXTURES: Mark each listed fixture with number installed or 'NA" if not applicable.
SIGNATURE: Signature ofappficant or agent. Date application one day submitted to the CPHU with appropriate fees and attachments.
ATTACHMENTS. A site plan drawn to scale, showing boundaries with dimensions, locutions of residences or buildings, swimming pools, recorded
c a,emems:, onsite sewage disposal system components and location, slope. of property, any existing or proposed walls, drainage
featare;, filled areas, obstn.cted areas, anJ surface water. Location of wells, onsite sewage disposal systems, surface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For reeidenccs, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonmaicb,miaf
establishmen+.s, a Boor plan showing the square footage of the establishment, all plumbing drains and Bxtum types, and other
features neccs_ury to determine composition and quantity of wastewater.
STATE OF FLORIDA PERMIT
DEPARTMENT OF HEALTIJ AND REHABILITATIVE SERVICES
--_-'--ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: AGENT:
CArol A. Van Horne Michael E. R1SSman Jr., P-E-
LOT: BLOCK: SUBDIVISION: P.S.M.
PROPERTY ID #: 1/37S/38E/42-01-134-0003-0105 [Section/Township/Range/Parcel No. or Tax ID Number
----------------------------------------- -------------------------
------------------------------------------------------
-TO BE COMPLETED BY ENGINEER, HEALTH,UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUS
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [X] YES [ ] NO NET USABLE AREA AVAILABLE: 5.0 ACRE
TOTAL ESTIMATED SEWAGE FLOW: 375 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2
AUTHORIZED SEWAGE FLOW: 7 500 GALLONS PER DAY 11500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1 SQFT UNOBSTRUCTED AREA REQUIRED: 1s2W SQF
�a�O %00
BENCHMARK FERENCE POINT LOCA'1(ION: 29.72
ELEVATION OF PROPOSED SYSTEM SITE IS .72 [INCHES( [ABOVE/ FLOW ENC REFERENCE POIF
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: j.HS7%�FT DITCHES/SWALES: �7/s FT 279 Y WET? [ ] YES [X] 2
WELLS: PUBLIC: R4AC�%LOf�'T LIMITED USE:6t7 FT PRIVATE: /�_ FT NON -POTABLE: n ne%
BUILDING FOUNDATIONS: 10 FT PROPERTY LINES: 7_ FT POTABLE WATER LINES: N/A I
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES (XI NO 10 YEAR FLOODING? [ ] YES [X] I
10 YEAR FLOOD ELEVATION FOR SITE: 27.33 FT MSL/NGVD SITE ELEVATION: ± 29.0 FT MSL/NG'
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
nsell #1 Color Textu e 14epth Munsell #/Color Texture Depth
to to
to to
to to
to to
to to
to to
to to
to to
to to
USDA SOIL SERIES: USDA SOIL SERIES:
OBSERVED WATER TABLE: 60 INCHES [ABOVE / ELOW EXISTING GRADE. TYPE: 11RCH / APPAREN
ESTIMATED WET SEASON WATER TABLE ELEVATION: (d° INCHES [ ABOVE �] EXISTING GRAC
HIGH WATER TABLE VEGETATION: [ ] YES [X] NO MOTTLING: [ ] YES [X] NO DEPTH: INCH
c
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCE
DRAINFIELD CONFIGURATION: [ ] TRENCH [ X] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY: DATE:
HRS-H Form 4015, Mar 92 (Obsotetes previous editions which may not be used) Page 3 o:
(Stock Number: 5744-003-4015-1)
STATE OF FLORIDA
:OUNTY OF S7../j�
The foregoing Instrument was acknowledged before me this _N�dey of//l( . 19 _/{( by John
%ampole who Is/er personally known o me or has produced �j as IdentilicaIf n.
SEAL
Notaar�yy�(gnature
e/ofi� A i4f/)/1//CO tlE 11
JO ANNE HONKONEN Printed Notary Signature ram.
: My COM"SSION / CC 234 90 RPIRES .
i.i My Commission Expires:
October ta, 19Sa (^6
e0N0E9 mina:aov FAIN IN:UHNiCE, UIL.
` olAIL U, I LUI.Uu/V
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM OPERATING PERMIT
Authority: Chapter 381, F.S. & Chapter lob-6, F.A.C.
New: Amgnd.Pd: Renewal:
Aerobic:_ Comm9rc1a1: Industrial/Manufacturing:_
GENERAL INFORMATION
Property Owner:_
Work Telephone
Address of Owner:
Owner's Agent:
Application/Permit Numbera za- Zs--
FC zip
Agent's Address: City: State Zip
Agent's Phone: Property Street Address:
City: State Zip
Section: / Townshlp:3,;5 Range:38E f arcel: Lot: Block: Subdivision: Unit:
EXISTING SYSTEM INFORMATION
Please complete those items shown below which are applicable to the existing permitted onsite sewage disposal system serving
the above referenced property: Onsite Sewage Disposal System Construction Permit Number (if known):
Septic Tank(s)/Aerobic Unit gallons Grease Trap(s) gallons Dosing Tank gallons
Drainfield size Is square feet installed In a: standard subsurface filled mound system
The drainfield layout Is In trenches absorption bed other (describe)
Onsite Well? Yes No System Setback to Wells fI. Lot Size Square Feet
Estimated sewage (low Into system Gallons/Day Based on
Number of businesses or dwellings (circle one) which are being served by this onsite sewage disposal system
Additional Comments:
COMMERCIALIINDUSTRIAL/MANUFACTURING FACILITY
Please attach a business survey form for each business which Is or will be served by the onsite sewage disposal system. Briefly
describe the type of activities that will be supported by the onsite sewage system serving this property.
What is the zoning designation for the property? Give a description of the zoning and examples of
approved businesses In this type of zoning:
AEROBIC TREATMENT UNIT
Dale of aerobic system installation approval:
manufacturer's Initial two year warranty? Yes
Type of Aerobic Unit: t
Is there air active service agreement on the aero
If yes, when does the service agreement expire?
Who is the authorized service company providin
Company Name
Address
Is the aerobic treatment unit still under the
Aerobic Unit Manufacturer:
Class II: Above 1500 Gallon Capacity:
Ore multiple aerobic units used on the site: Yes No
? Yes_ No Please Attach a Copy of the Agreemenl
to your unit?
Phone Number
State_ Zip
I hereby codify That the above Information Is accurate and a rollerlion of the actual condilions existing on the above referenced property. I understand that any
chango of ocrupancy or tenancy at the above location will require mo to file an anmendmmd to this opomating permit.
Applicant's signature:
Application Status:
Disapproved: Date / / Reason:
Date—/4
By: Title: CPHU
Approved: __ Date -- / — /
By: _ — Title: CPFIU
HnS-11 form 4081, January 1992 Page 1 of --
BUSINESS SURVEY C74 K16CVCLG
AN ATTACHMENT TO HRS-H FORM 4081
ASSESSMENT OF WASTE HANDLING AND BUSINESS ACTIVITIES
New:. '
Renewal:
Change of Tenancy/Amendment:
Application/Permit Number
Please provide the following Information regarding your business facilities and the activities which will take place on site.
Business Name
Business Owner's Name
Business Mailing Address
City State
Street Address of Business
City_ State
Occupational License #
YIf
stow many employees will use this facility Hours of operation
What type and number of sanitary facilities will be available at this location: Anticipated flow: gpd Based on
Toilets Urinals Hand Washing Sinks Utility Sinks
Showers Floor Drains Equipment Drains(Describe)
2-Compartment Sinks3-Compartment Sinks
Laundry Facilities Garbage Grinder/Disposal
Commercial Dish Machines (heat sanitizing) (chemical sanitizing)
Can Washing Facilities Other(Describe)
Completely describe the activities which will take place at your business location (le. types of waste generated, volume of raw
materials handled, amount of wastes generated, equipment used in the process):
List any chemical compounds routinely used in your business: Attach Material Safety Data Sheets for Compounds Used or Stored
Name Gal or Ibs/Month Amt on hand Storage Method Disposal Method SIC Code
Please list licensed waste haulers removing wastes from your site.
Company Name
Describe how emergencies, such as spills, will be handled at this site:
Type of Waste Removed
As the business owner, I understand that Information contained In this application serves as a basis for determining the suitability of the onsite sewage disposal
system to serve the business described above. Information contained herein is an accurate rellection of the activities which will be allowed on this site. I also
agree to pomform any testing as may be required by this permit, and collection & analysis of samples will be done of my own expense by a state certified
laboratory. I also agree to notify the county public health unit of fire change In any material fact used to determine the issuance of this permit
Business Owner or Agent's Signature: Date
Property Owner or Agent's Signature: Date
TO BE COMPLETED BY COUNTY PUBLIC HEALTH UNIT:
Kill monitoring be required: Yes___ No_ Sample location_____ —-
Compounds to be examhted:___ _
Is DER/ County Haz Waste review required: Yes__ No__ Monitoring Frequency___
Survey disapproved _Dale: / / Reason:
Survey approved:
CPHU Date: / /
HRS-H Form 4081A, January 1992 Page _ of _