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STATE OF FLORIDA PERMIT NO. — -
F 3 DEPARTMENT OF HEALTH DATE PAID: 2
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: 3�5°`zl
SYSTEM RECEIPT #:
E APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ ] New System [] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment [ ] Temporary [ ]
� APPLICANT:
AGENT: % j� `f /r -� r �� y �3
�� ac7t tz�LS ,L.,L� TELEPHON / f %� 2&-)-_ L1U C� g
MAILING ADDRESS: C ��%{ ��JL �iG�l�� ;'I�y ! c �✓ �-�f C/L c� `L G
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: 1 BLOCK: SUBDIVISION: ��/�.{-//�� fL PLATTED:
PROPERTY ID # : ����� '� ����- v�y ' J ZONING: I /M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: d( (3./V-ACRES WATER SUPPLY: [ ,,,]"PRIVATE PUBLIC [--']<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y/'.O ]
DISTANCE TO SEWER: FT
PROPERTY ADDRESS: 70141 SMetL i f��/ � �_ ovo r e// ,l , Udi
is n :349-&o
DIRECTIONS TO PROPERTYC P4/T 4 f (� i [ i (,� 4./% ��� -~ i�G� l-�-
BUILDING INFORMATION [RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
2�
3
4
Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE: L DATE: f Q
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4