HomeMy WebLinkAboutHealth Department Septic Permit f
' le copy
PERMIT #:66=SF=1724800
STATE OF FLORIDA APPLICATION #:AP1266141
Yr _
w DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT RECEIPT #:
WS DOCUMENT #: PR1042243
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Sharina Baka
PROPERTY ADDRESS: TBD Millisa Ter Fort Pierce, FL 34947
T: 4 BLOCK: SUBDIVISION: Hartman Heights
PROPERTY ID #: 2417-602-0004-000-2 [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.
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SYSTEM DESIGN AND SPECIFICATIONS
T [ 1,050 ] GALLONS / GPD Septic new CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
[ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 667 1 SQUARE FEET Drainfield new SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [X1 MOUND [ ]
I CONFIGURATION: [ ] TRENCH [x] BED [ ]
N
F LOCATION OF BENCHMARK: site BM nail in rd w side of cul de sac circle
II ELEVATION OF PROPOSED SYSTEM SITE [ 4.00 lI INCHES FT ] [ABOVE HELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 1.00 1 [ INCHES FT ] ABOVE BELOW]BENCHMARK/REFERENCE POINT
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D FILL REQUIRED: [23.001 INCHES EXCAVATION REQUIRED: [ 38.001 INCHES
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons(2 per bedroom),for a total estimated flow
of 400 gpd.
T The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with
H s. 64E-6.013(3)(f), FAC.
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(SPECIFICATIONS BY: Brian J Ingram TITLE: Environmental Specialist II
(APPROVED BY: %'' TITLE: Environmental Specialist II
p St. Lucie CHD
Brian VIngrarn
DATE ISSUED: 12/16/2016 EXPIRATION DATE: 06/16/2018
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 AP1266141 SE1016671
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NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one(21) days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The
Agency Clerk's facsimile number is 850-413-8743.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order
will constitute a waiver of your right to an administrative hearing, and this order shall become
a 'final order.
Should this order become a final order, a party who is adversely affected by it is
entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings
are governed by the Florida Rules of Appellate Procedure. Such proceedings may be
commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the
Department of Health and a second copy, accompanied by the filing fees required by law,
with the Court of Appeal in the appropriate District Court. The notice must be filed within 30
days of rendition of the final order.
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Dec 06 ,2016 05:19PM HP FaxAmedcan Drilling 8634678485 page 1
STATEOF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR,MODIFY,OR ABANDON A WELL Permit No. 7r.' — +
L7 Southwest Florida Unique ID
PLEASE FiU.OUT ALL APPLICABLE FIELDS
n Northwest ('Denotes Required Fields Where Applicable) Permit Stipulations Required(See Attached)
z. ❑St,Johns River 'Ihe wator werlydn!mcrnns asQenaible for conyXcnbg
y D South Florida tlrb Wrnudtdrawnrdrttp th tpenniruppllCatioat ietll6 52.524 Quaa No. Dellnbrllion No.
I]Suwannee River npprapnea¢,n�orrrinurrxmrywhrnrnpplirrtblr.
13 DEP wUPMNP Application No,
0 Delegated Authority(If Applicable) ABUlItTHISLINE.FOR OFFICIAL USE OMLO
1,
•Owner,Le ga "Address 'City "State "ZIP Telephone Number
2, 1-10+ !l IT tip!N\i ce .x-c, 7-- 2 1 . .
by o etio - dd[ess,Ra Nam of u r Cf
3. a
'Parcel ID No.(PIN)or Alternate K y(Ciro One f ,�1 (,,. of Block nit
14• j , I f��L L7 i i Ft 1. heck if 62-524:❑ Yes�o
Action or Land Gran "Town hip 'Range County ubdivisio
�. merr c e r� r; �l L_ A(6A�� --��, f 1
Water ll ontracto�r!x�1 'License Number TelIng,ephone Number cE--maiil Address 7�
6. .�-t e4i,cConj a toC's Atld ss � - 0 0 City x -'4
7. 'Type of Work: �ConstrucllQn ❑ Repair ❑ Modification[] Abandonment
S. 'Number of Proposed Wells
t Reesnn totRepair Modification orAbruiaavnenY
g. 'Specify Intended Use(s)of Well(s): P
MON
Domestic H
Landscape Irrigation ❑ Agricultural irrigation E
Site Investigations
Bottled Water Supply Recreation Area Irrigation ❑ Livestock Monitoring
❑ Public Water Supply(Lhnited Use}DOH) ❑ Nursery irrigation ❑ Tesi
Public Water Supply(Community or Non-Community/DEP)❑ Commerclavindustrial Eartt>-Coupled Geothermal DEC 16 2 6
Class I Injection ❑ Golf Course Irrigation ❑ HVAC Supply
HVAC Return
Class V Injection:❑ Recharge ❑ Commercialilndustrial Disposal ❑ Aquifer Storage and Recovery❑ Drainage
Remediation:❑ Recovery❑ Air Sparge ❑ Other (Describe) I FDQMJn RtMeite ounty
❑ Other (Describe) EA
10.Distance from septic SysteM if 5200 R. t 1.Faciiit esorlption 12.Estimated Start Date
13'Estlmated Well Depth LLILft. 'E^s�ti/m�ated Casing Depth, fL Primary Casing Diameter in. Open Hole: From To ft.
14.Estimated Screen Interval:From (; Uo-1 a "1
15`Primary Casing Material: Slack Steel Galvanized PVC Stainless Steel
Not Cased Other.
16.Secondary Casing: Telescope Casing Liner Surface Casing Diameter in.
17.Secondary Casing Material: Black Steel Galvanized PVC Stainless Steel Other
IVIVIethod of Construction,Repair,or Abandonment: Auger Cable Tool Jetted Rotary Sonic
Combination iTwa or More Methods) Hand Driven(Well Point.Sand Point) Hydras Direct Push)
Horizontal Drilling Plugged by Approved Method Other triesmuer
1fl.Propose,Grouting Interval for the Primary,Secondary.and A
From Tad) Seal Material( eenicniie Neat Cement __ Other )
From To Seal Material( Bentonite Meet-Cement Other )
From To Seal Material( Bentonite Neat Cement Other )
From To Seal Material( Bentonite Neat Cement Other )
20,Indicate total number of existing wells on site List number of existing unused wells on site
21,1Is this well or any existing well or water with I eilthe owner's contiguous property eoveretl under a ConsulnpttveMlater Use Permit(CUPMlUP)
or CUPIWUP Application? Yes No If,yes.complete the follovang:CUPIWUP No. District Well ID No.
22.Latitude it
23.Data Obtained From: GPS M� Survey Datum; NAO 27 NAD 83 WGS 84
I huneby edtdtr that l tar eontily with thu epplCable cola IVia4 flails, mitlea irve Code,a..Wet n wales I:Ymly purl l am Pie owner at in prepdny.hal die tatmmehun provided is ac�oprolo,and that trim acute army
use perm¢ora,breral rearwreo perodt,;iwednd,has been or v,16 ba ed plar ao odmmaricamunt Cr well tcspvmN146eG ultdor CheDU;r]i]Flwlde Statutes.m man Ir e,property aboadon this welt or.I ra,dpr 6.0 an,
consputded.I bathercbdryrhnteb inlornwtim ri m edad m this apprcadonis mi Nivata and thati i9l abinn the nbem b,the owner,that Ule NFnaadnn ptowdr cure Will.tl hwe mhvm:d Ne ownnrofthen
ner46,my aP.—I from elherkdQm.eteta,or is-1 vernimn4,i,eppdnt+le,Iabtee to povpa artPO ra6pansihi4dae as.rated Q e eras tawN kennel of oil SOM ar Deledetad A,nhw,ty ettcas
campleba,repan to tlw IXahiq MPth+3r1 days atlet Mmp7enan nl he mnslrocliph,repnb.madeasfm,,ar ID the wd,sae Aptind Me crosbu n r C. ratlon, aDOndonrttenl attdlaraed dy tNe Darml.
abandaran.0 Wheeled M thla pmma.w it r1lost it pn,s,Nctl ocrurs real,
'S ,atu. o Contractor 'License No. -Signature of 114vner o A on /'Date
VELOW11115 LINE-FOR OFFICIAL USE ONLY
Approvel Granted By, "� — Issue Date � 4 Expira0on Date Hydrologist Approval
bh,ub
Fee Received $ Receipt No. Check No.
THIS PERMIT IS NOT VALID UNTIL PROPERLY SIGNED BY AN AUTHORIZED OFFICER OR REPRESENTATIVE OF THE.WMD OR DELEGATED AUTHORITY. THE
PERMIT SHALL BE AVAILABLE AT THE WELL SITE DURING ALL CONSTRUCTION.REPAIR,MODIFICATION.OR ABANDONMENT ACTIVITIES.
DEP Form:62.532.900(1) Incorporated in 62-532.400(1),F.A,C. Effective Data,.October 7,2010 Page 1 of 2
i 4 St. Lucie County Health Department
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OYI 5150 NW Milner Dr Port Saint Lucie, FL 34983
HF I A
PAYING ON: PERMIT#•56-SF-1724800 BILL I=#:56-BID-3315956 CONSTRUCTION APPLICATION#:AP1266141
RECEIVED FROM: Sharina Baka AMOUNT PAID: $ 515.00
PAYMENT FORM: CREDIT CARD PAYMENT DATE: 12/06/2016
MAIL TO: Sharina Baka
FACILITY NAME :
PROPERTY LOCATION:
TBD Millisa Ter
Fort Pierce, FL 34947
Lot: 4 Block:
Property ID: 2417-602-0004-000-2
EXPLANATION or DESCRIPTION: QUANTITY FEE
11 -OSTDS Construction Application and Plan Review,New 1 $ 100.00
123 OSTDS Construction Site Evaluation 1 $ 115.00
126-OSTDS Construction Permit(New or Mod, Amendment) 1 $ 55.00
127-OSTDS Construction System Inspection 1 $ 75.00
128-OSTDS Construction System Inspection Research Fee 1 $ 5.00
133-OSTDS Construction Reinspection� 1 $ 50.00
-1 - Surcharge (All) 1- '✓- $ 15.00
-1 - OSTDS New Permit Surcharge -}- �-��'^��� $ 100.00
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RECEIVED BY: VanceMH 56-PID-3.1.52356
5 q-,2-,5q 0'2,
5r -/72, Z'
STATE OF FLORIDA PERMIT No.
DEPARTMENT OF HEALTH DATE PAID:
a ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
SYSTEM RECEIPT #:
•~`°°we APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ .] New System [ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair ( l Ab ent [ ] Temporary [ ]
APPLICANT: ,
AGENT: ` 5 TELEPHONE-Da �_ `I� ! �
MAILING ADDRESS, / �A 1V c\ I Q 2. 1 L( 9 J 1
aaaaaaaaaaaa==aaaaa===-c===aooa=a=a=-a=a=aaaa=a=aaaaaacaacaaa_caaaa---_-_..-_---aaaaa=aa=-
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.
1PROPERTY INFORMATION
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LOT: `� BLOCK; SUBDIVISION: N0,(4Mi&D PLATTED:
PROPERTY ID #: ® "'���/ ,�` coo I/-O OCR -?-zONING: I/M OR EQUIVALENT: [ Y
PROPERTY SIZE: ACRES WATER SUPPLY: [ P VATE PURL I<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / DISTANCE TO SEWER: FT
PROPERTY ADDRESS: c 1 \�
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [%,41 RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Scrft Table 1, C a ter 64E-6, FAC
5 �� +� ✓
3
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[ ] Floor/Equipment Dr s [ I Other (Specify)
SIGNATURE: DATE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
,Incorporated 64E-6.001, PAC Page 1 of 4
C � STATE OF FLORIDA APPLICATION # AP1266141
a;€ DEPARTMENT OF HEALTH PERMIT # 56-SF-1724500
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM DOCUMENT # SE1016671
SITE EVALUATION AND SYSTEM SPECIFICATION
� we .
APPLICANT: Sharina Baka
CO TRACTOR / AGENT: Sharina Baka
LOT: 4` BLOCK:
SUBDIVISION`: Hartman Heights ID#: 2417-602-0004-000-2
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TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST
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:- 1.30 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ RESIDENCES-TABLET / OTHER-TABLE 2 ]
AUTHORIZED SEWAGE FLOW: 1950.00 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED'AREA AVAILABLE: 1500.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1000.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION: site BM nail in rd w side of cul de sac circle
ELEVATION OF PROPOSED SYSTEM SITE 4.00 [ INCHES / FT ] [ ABOVE / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: FT DITCHES/SWALES: 100 FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 100 FT NON-POTABLE: FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: FT
SITE SUBJECT�TO FREQUENT FLOODING? [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO]
10 YEAR FLOOD ELEVATION FOR SITE: FT [ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
USDA SOIL SERIES:Winder loamy sand USDA SOIL SERIES:Winder loamy sand
Munsell#/Color Texture Depth Munsell#/Color Texture Depth
10YR 3/1 Loamy Fine Sand 0 To 7 10YR 311 Loamy Fine Sand 0 To 7
10YR 4/1 Fine Sandy Loam 7 To 18 10YR 4/1 Fine Sandy Loam 7 To 18
10YR 5/1 Fine Sandy Loam 18 To 38 10YR 5/1 Fine Sandy Loam 18 To 38
10YR 5/6 CMN/PRM RF 19 To 38 10YR 5/6 CMN/PRM RF 19 To 38
10YR 5/1 Loamy Fine Sand 38 To 50 10YR 5/1 Loamy Fine Sand 38 To 50
5GY 6/1 Loamy Fine Sand 50 To 72 5GY 6/1 Loamy Fine Sand 50 To 72
OBSERVED WATER TABLE: 61.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ]
r ESTIMATED WET SEASON WATER TABLE ELEVATION: 19 INCHES [ ABOVE / BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ]YES [X ]NO MOTTLING: [X]YES [ ]NO DEPTH: 19.00 INCHES
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SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Sand/0,60 DEPTH OF EXCAVATION: 38 INCHES
RAINFIELD CONFIGURATION: [ ] TRENCH [X] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA
WSWT determined using USDA WSS and soil borings.
10YR5/6 Cmn Prom RF>2%starting at 19"In 10YR5/1 matrix in SB2.
SB1 3"below BM.SB2 5"below BM.
SITE EVALUATED BY: / DATE: 12/16/2016
Ingram,Bria (Title:Environmental Specialist II)(ENVIRONMENTAL HEALTH)
PH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 3 of 4
AP1266141 EID1724800 v 1.0.2
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