HomeMy WebLinkAboutConnection to Existing SepticSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ ] New System
[ ] Repair
APPLICANT:
[✓] Existing System
[ ] Abandonment
AGENT: f r14 ! y ( • 5; mtept4e
MAILING ADDRESS: e4900 6OW11,/0nld
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] Holding Tank [ ]
[ ] Temporary [ ]
. �Sz�
Innovative
TE LE PHONE : D-N Z 143
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:
PROPERTY ID #:
SUBDIVISION: PLATTED:
ZONING: I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE:=�� ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FSt? [ Y / N ]
PROPERTY ADDRESS: �� �l(lOZC/ZJ/ lj"
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
2
3
4
DISTANCE TO SE�WER:
� , &
FT
[ ] RESIDENTIAL [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
DATE : �/ZG 20 Z/
Page 1 of 4
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
TELEPHONE: Telephone number for applicant or agent.
MAILING ADDRESS: P.O. box or street, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK, Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a
SUBDIVISION: recorded subdivision, a copy of the lot legal description or deed must be attached.
DATE OF SUBDIVISION: 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.
PROPERTY ID#: 27 character number for property. CHD may require property appraiser ID # or
section/township/range/parcel number.
ZONING: Specify zoning and whether or not property is in I/M zoning or equivalent usage.
PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,560 square feet)
exclusive of all paved areas and prepared road beds within public rights -of way or
easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or
other such bodies of water. Contiguous unpaved and non -compacted road rights -of -way
and easements with no subsurface obstructions may be included in calculating lot area.
WATER SUPPLY: Check private or public <= 2000 gallons per day or public > 2000 gallons per day.
SEWER AVAILABILITY: Is sewer available as per 381.0065, Florida Statutes, and distance to sewer in feet.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street
or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 64E-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 fully screened patios or decks. Based on
outside measurements for each story of structure.
BUSINESS ACTIVITY: For commercial/institutional applications only. List number of employees, shifts, and
hours of operation, or other information required by Table II, Chapter 64E-6, FAC.
FIXTURES: Mark Floor/Equipment Drains or Others and specify item or "NA" if not applicable.
SIGNATURE /DATE: Signature of applicant or agent. Date application submitted to the CHD with appropriate
fees and attachments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or
buildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope of
property, any existing or proposed wells, drainage features, filled areas, obstructed areas, and 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 residences, a floor
plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, a floor
plan showing the square footage of the establishment, all plumbing drains and fixture types, and other features necessary
to determine composition and quantity of wastewater.