HomeMy WebLinkAboutSewageTIIE yL� r
STATE OF
DA
DEPARTMENTLOFIIa-
HEALTH DATEPAID : ✓�~F kci
31�
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: S CL
SYSTEM RECEIPT #: 0S7,aa
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
New System Existing System Holding Tank Innovative
JL Repair J� Abandonment [EI Temporary (x �i{�CLp�1Ci'( }
J
APPLICANT: Travis Haag 35
AGENT: Septic Environmental Services Inc. TELEPHONE: 772-201-8079
' MAILING ADDRESS: 4738 Selvitz Rd Fort Pierce, Florida 34981
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: n/a
PROPERTY ID #: 3412-140-0001-000-2 ZONING: Res. I/M OR EQUIVALENT: [ YQ NQ✓
PROPERTY SIZE: 1.99 ACRES, WATER SUPPLY: Jo PRIVATE PUBLIC C3 <=2000GPD [0]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ YO N ✓D DISTANCE TO SEWER: n/a FT
PROPERTY ADDRESS: 6789 S Indian River Dr Fort Pierce, Florida 34982
DIRECTIONS TO PROPERTY, see attached directions
BUILDING INFORMATION
Unit Type of
No Establishment
1 Single family
[Q] RESIDENTIAL [0] COMMERCIAL r
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
3 2,038 300 GPD
2 �f �S r�!4 2, 50 No 6ej (,Yj
3
4
Ch Floor/EquIpment Drains �[Q] Other (Specify)
SIGNATURE:
Dh 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
DATE: August 20, 2019
Page 1 of 4
'I' LALI H
PAYING ON:
RECEIVED FROM:
PAYMENT FORM:
MAIL TO: Travis Haag
St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
#. 56-SF-1775317 BILL DOC #:56-BID-4366835 CONSTRUCTION APPLICATION #: AP1429758
SEPTIC ENVIRONMENTAL SERVICES AMOUNT PAID: $ 35.00
CREDIT CARD 105322 PAYMENT DATE: 08/21/2019
'FACILITY NAME:
PROPERTY LOCATION:
6789 S Indian River Dr
Fort Pierce, FL 34982
Lot:
Property ID: 3412-140-0001-000-2
EXPLANATION or DESCRIPTION:
139 - OSTDS Application Approval Existing, No Insp
Block:
QUANTITY FEE
1 $ 35.00
RECEIVED BY: MontanezNM AUDIT CONTROL NO. 56-PID-4065399
t
i�
APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
I
Travis Haag
CONTRACTOR / AGENT: Septic Environmental Services Inc.
LOT: BLOCK: SUBDIV:
PERMIT #
ID# : 3412-140.0001-000.2
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
T/LV-IX14t( 'z
[ to GALLONS SEPTIC TANK/GPD ATU LEGEND: 70-143-11DC4 MATERIAL: Polyethylene BAFFLED: [Yo NE
[ ] GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL: BAFFLED:"[Y[] N[:]
[ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL:
[ ] GALLONS DOSING TANK LEGEND: MATERIAL: # PUMPS:[ ]
-- ---- ----------------------------
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON 08 / 20 / 19 BY Accurate Septic , HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY DIMENSIONS / FILLING / LE_ GE ARE FREE OF OBSERVABLE
DEZCiT S O L S, AND HAVE A_ [ SOLIDS DEFLECTION DEVICE OUTLET FILTER DEVICE ] INSTALLED.
6�� S.E.5 INC. Augus120, 2019
SIGNATURE OF LI NSED CONTRACTOR BUSINESS NAME DATE
EXISTING DRAINFIELD INFORMATION
[ 540 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [be]
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ]
TYPE OF SYSTEM: =] STANDARD [C3 FILLED [M] MOUND rr7]
CONFIGURATION: C]. TRENCH [[� BED [0] Infiltrator
DESIGN: [C]] HEADER [Cll D-BOX [Ml GRAVITY SYSTEM DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE 27 INCHES [ ABOVE BELOW]
, SYSTEM FAILURE AND REPAIR INFORMATION
DIMENSIONS: -01-1
DIMENSIONS: X
[ 2017 ] SYSTEM INSTALLATION DATE TYPE OF WASTE [0] DOMESTIC [=1] COMMERCIAL
[ 300 ] GPD ESTIMATED SEWAGE FLOW BASED ON j]] METERED WATER E]] TABLE 1, 64E-6, FAC
SITE [0] DRAINAGE STRUCTURES [0] POOL
CONDITIONS: [[]] SLOPING PROPERTY [71]
NATURE OF [=] HYDRAULIC OVERLOAD
FAILURE: [ED] DRAINAGE / RUN OFF
FAILURE SEWAGE ON GROUND
SYMPTOM: [0] PLUMBING BACKUP
[E3] PATIO / DECK [0] PARKING
[O] SOILS [0] MAINTENANCE
[01 ROOTS [0] WATER TABLE
[[=] TANK
[0]
[C3] SYSTEM DAMAGE
[0 ]
[[:J] D BOX/HEADER [p] DRAINFIELD
REMARKS/ADDITIONAL CRITERIA Tank and drainrield certification both are working at this time.
SUBMITTED BY: 4(i(iGG����'/y�j�' TITLE/LICENSE SR0171802
DH 4615, 08/09 (Obsoletes previo s editions which may not be used)
Incorporated 64E-6.001, PAC
DATE: August 20, 2019
Page 4 of 4