HomeMy WebLinkAboutSewage Application Permit�znte
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
s SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
PERMIT NO. 5b'5er' X?-d 5-13?
DATE PAID: 1S
FEE PAID:
RECEIPT #:
APPLICATION FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair ( [ ] Abandonment [ ] Temporary [,/ ] Plan Review
APPLICANT: .} �7 hvi 130
AGENT: l_5 Lei c�� /�y- i� I c� r , 77 TELEPHONE:
MAILING ADDRESS: 2c7� C�� ,� ►�� �tJc7t�i1 ��7 (� 5
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 489.551, FLORIDA STATUTES. IT I$ 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:
1,317 —Y 2 2 -- �/ o �- �?c�cl
PROPERTY ID # : - , , ; {` S. ZONING, I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: ACRES WATER SUPPLY: l�J\PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065; FS? [ Y/NN ] DISTANCE TO SEWER: - 2 FT
PROPERTY ADDRESS; 1 5� S 'S c)G > N'� t� "'gy p' a/ �' fel<-C�
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
bV_3 RESIDENTIAL
[ ] COMMERCIAL
Unit Type of
No. of
Building
Commercial/Institutional System Design
No Establishment
Bedrooms
Area Sqft
Tabjl%e 1, Chapter 64E-6, FAC
k7lo�g
/
2
3
4
[ ] Floor/Equipment Drains
SIGNATURM
] Other (Specify)
DH 4015, OQr/09 (Obsoletes previous editions which may not be used)
Incorporated .64E-6.001, FAC
DATE. ...
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