HomeMy WebLinkAboutSeptic Permit Page #1, 2.22.210
F� STATE OF FLORIDA PERMIT NO.
DEPARTMENT OF HEALTH DATE PAID: P 1
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
<, SYSTEM RECEIPT #:
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[v/] New System [ ] Existing System [ j Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment [ ] Temporary [ ]
APPLICANT: George & Tracy Shapard
AGENT: RJM Custom Homes TELEPHONE: (561) 267-7476
MAILING ADDRESS: 6917 Vista Parkway North Suite #1 WPB, FL. 33411
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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: 23 BLOCK: SUBDIVISION: Timberlake Estates PLATTED:
PROPERTY ID #: 2302-601-0027-000-3 ZONING: X I/M OR EQUIVALENT: [ NO J
PROPERTY SIZE: 0.56 ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [V/]<=2000GPD [./]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ No J DISTANCE TO SEWER: >1000 FT
PROPERTY ADDRESS: 1530 Pineburke Lane Fort Pierce, FL. 34947
DIRECTIONS TO PROPERTY: Turn left onto W. Angle Road, turn left onto Timberlake Drive, turn left onto Pineburke Lane
then straight to address of 1530 Pineburke Lane.
BUILDING INFORMATION RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sctft Table 1, Chapter 64E-6, FAC
1 SFD 4 9571
2
3
N
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE:
DATE:
DH 4015, 08/09 (Ot�snletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4