HomeMy WebLinkAboutSewageMission:
To protect, promote & improve the health
of all people in Florida through integrated
state, county & community efforts.
(Ashton Septic Tanks Inc.)
376 Cyclone Drive
Fort Pierce, FL 34945
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Vision: To be the Healthiest State in the Nation
May 12, 2015
Rick Scott
Governor
John H. Armstrong, MD, FACS
State Surgeon General & Secretary
RE: Contingency Letter
Application Document No: AP1188127
Centrax Permit Number: 56-SF-1415531
OSTDS Number:
Rebecca Percy
11298 Muller Rd
Fort Pierce, FL 34945
Lot: Block: Subdivision:
Dear Applicant:
This will acknowledge receipt of an application dated 05/08/2015 for a permit to use an
existing onsite sewage treatment and disposal system located on the above referenced
property.
From a review of your completed application, it has been determined your existing system is
adequate for the proposed use.
One bathroom addition
ir. If you have any questions on this matter, please call our office at (772) 873-491,
Si cerel ,
ictor Faconti, Env. Sup II
Enclosures \
cc:
Florida Department of Health www.FloridasHealth.com
in ST. LUCIE COUNTY TWITTER:HealthyFLA
5150 NW Milner Dr, Port Saint Lucie, FL 34983 FACEBOOK:FLDepartmentofHealth
PHONE: (772) 873-4931 . FAX: (772) 873-4893 1 YOUTUBE: fldoh
STATE OF FLORI=A
DEPAR7TBI3T OF HEALTH
ONSITE- SEWAGE AM DISPOSAL
'., SYSTEM
°e APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
C I New System ><f Existing System. [ ] Holding Tank
I ] -Repair j ] Abandonment I ] Temporary
APPLxcMgT: b P�CIIGl� 'r211'l`
AGENT : �tS �TIM Se,ml- C G' T ILS
1&mnm ADDRESS:
L
PERMYT NO.
P •�7�7 � 7
I l
•DATE PAID:
I\,
FEE PAID:
RECEIPT 0:
[ 1 Z OVative
I 1
TELEMONE: 77.2 Z/6.- 2'9?7
314-g45'
Tb BE COMPLETED BY APPLICANT OR APPLIMMTrS AUnDORIMM AGENT. SYS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO'489.105(3)(m) OR'a89.552, EZORMA STAT=s- IT. IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DO AT3:ON OF TEE DATE TSE LOT MS CRFAM�M OR
P=•&TTEn (Mbd/DD/YY) IF REQUESTING 'CONSIDERATION OF STATUTORY GRAr DM2LTE 'R PROVISIONS.
LOT: BLOCK: SUBDIVISION: P"eCjJ4�% PLATTED:
i
Pi20PERTY m : �333`
I % � i. � -��� r ZONING: I/M OR EQDIVAMM:
[ Y / N I
PROPERTY SIZE: 2� r
ACRES RiTER SUPPLY: ><I PRIVAT9 PUBLiC [ ]<=LOOOGPD [
3>2000GPD
IS SEAEIt AVATLABT•E AS
PER 381.0065, FS?
[ Y,/Jl1 -DISTANCE TO SEWER:
A4 FT
'PROPERTY ADDRESS: 112
I +
6 l ) 1 l'e ✓
K'd
DIRECTIONS TO PROPERTY:
BUILDING INFOE + TION RESIDENTIAL [ I =fidERCIAL
Unit Type of No. Of Building Commercial/Institutional System Design
No .. Establishment Bedrooms Area Sgft Table 2, Chapter 64E-6, FAC -
2 &aihvom A W4,
3 3
)Chtg4 .33
4
C ] Floor/E/ggn±pmeent Drains [ I� Other (Spec; y)
kv
DATE:.
DH 4015, 08/ 9 (Obsoletes pievious editions which may not be used)
Incorporated 64E-6.001, PAC za, Pagre i of 4
r
CONTRACTOR / AGENT: _A s *4o-n p i L. --rny .� . r
LOT.: BLOCK: sIIBDiV: J Pn..)9'6 • ID#• 2333
TO BE 'COMPLETED BY FLOPIDA 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
[ 10.01 GALLONS SEPTIC TANK/GPD ATU. " . LEGEND: 28 "01 -�'-OB 136jiJATERTAL : ME= D • y / Nl
[ ] GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL,: _ BAFFTFD/ N
7
[ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL-
[ ] GALLONS DOSING TANK LEGEND: MATERIAL: #[ PUMPS:[ 7
I CERTIFY THAT THE LISTED TANKS VERE PUMPED ON / •/ BY HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS /FILLING /_I,$GEND I ARE FREE OF OBSERVABLE
DEFECTS OR LEAKS, AND HAVE A [ SOLIDS DEWCT ON D VICE•/ OUTLET FILTER DEVICE.] INSTALLED.
S4 I G1i�d/lL
SIGNATURE OF LICENSED CONTRACTOR BUSINESS NAME DATE
3XISTING DR2INF2ELD INFORMATION
[ 7.2 O] SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS'- OS X
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS:. X
TYPE OF SYSTEM: [ ] STANDARD [ ] FILLED MOUND [ ]
CONFIGURATION: [ ] TRENCH BED
DESIGN: bm<' HEADER [ ] D-BOX ><_ GRAVITY SYSTEM [ ] DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE INCHES [ ABOVE / BELOW]
SYSTEM FAILURE AND REPAIR INFORMATION
[ 20131
SYSTEM INSTALLATION DATE
TYPE .OF WASTE it- T DOMESTIC
[ ] COMMERCIAL
[ �d� ]
GPD ESTIMATED SEWAGE FLOW
BASED ON
[ ]
METERED WATER
TABLE 1, 64E-6, FAC
SITE
[ ] DRAINAGE STRUCTURES
[ 7
POOL
[ ]
PATIO / DECK
[ ] PARKING
CONDITIONS:
[ ] SLOPING PROPERTY
[ ]
NATURE OF [
] HYDRAULIC OVERLOAD
[ ]
SOILS
[ ]
MAINTENANCE
[ ] SYSTEM DAMAGE
FAILURE: [
] DRAINAGE / RUN OFF
[ ]
ROOTS
[ ]
WATER TABLE
[ J
LURE
f --SEWAGE- ON' GROUND
[ ]
TANK
_... [ . ]
BOX/HEADER
[ ] DRAINFIELD
SYMPTOM: [
. ] PLUMBING BACKUP
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REMARKS/ADDITIONAL.CRITERIA
IV O
SUBMITTED BY: w TI-TLE/LICENSE 59-OS' 0di<•J DATE:t�
DH 4015,.08/09 (Msoleteif previous• editions which may not be used),
Incorporated 6=6.001, FAC Page 4 of 4