HomeMy WebLinkAboutSeptic Demo applicationPERMIT NO -
OF FLORIDA
DEPARTMENT OF HEALTH NT AND DISPOSAL FEE PAID
ONSITE SEWAGE s9 s
SYSTEM J41T
EATME RECEIPT
1 `
APPLICATION FOR
CONSTRUCTION
APPLICATION FOR.a Holding Tank� I Innovative[ } New System E Existing system [ 3
I Temporary
Abandonment TemporaryC I
Repair
/ Q
APPLICANT'
; %f' �/ /✓�� ® L✓ P/J
TELEPHONB. ,,js 2- zsL- S�Yy-f
AGENT:
D . —',ZAP-AMM64-AW
CANT, S AUTHORIZE
TO --
BE COMPLETED By APP11"CANT OR APPLI 89-552, FLORIDA STATUTES' IT IS THE
PERSONBY A «F 4 THE DATE THE LOT
APPLICANT'S RESPONSIBILITY TO PROVIDE ►M
PLATTED(MM/3)D/YY) IF REQUESTING CONSIDERZiffoX OF STATUTORY
PLATTED I
LOT : BLOCK: SUBDIVISION..
-Y//V -/l/- 000 /.�OOD 7 z�av � OR EQUIVALENT; i YIN 1
PROPERTY ID # z PROPERTYSIZE •. / YO 0 ACRES WATER SUPPLY. E t I PRIVA' PUBLIC [ ] <=2 a 00GPD [ 1 >2 0 0GPD
IS SEWER AVAILABLE AS PER 381. 065, FS? [ YO]
DIsxAWcE To SEWER: F
�7 ��/ ofe����. /Zook , ��, 1�. l • -
PROPERTY ADDRESS'
DIRECTIONS o PROPERTY. � 7-0
BUILDING INFORMATION
RESIDENTIAL t I COMMCIAL
Unit Type of No. of B,ilding commercialJInstit-ational system Design
Bedrooms Area Sgft 'Table s, /C1[a ter!.64K- 6, IF
AC
No _ Establishment - ---" �e'SI� ee%A+ /1'R �GI+'t0��0''�
3
4 —
T 3 Pleror/Ea x pxr€ex t Yir a other (Specify)
SIGNATURE. w - --- --
Dii 4015, 88/89 (U£-,soletes previous editions which
Incorporated; 4E-. tea PAC
DATE:
nOt be used)
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