HomeMy WebLinkAboutApplication For Construction (Sewage)cte sr�
STATE OF FLORIDA
DEPARTMENT OF HEALTH
u �D ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
1°-so APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
fie« Nam. 501-3c)LAS
PERMIT NO.-%"�F-A024 1Q'3
DATE PAID:
FEE PAID: Tq
RECEIPT #:
[r/l New System [ ] Existing system [ ] Holding Tank •[ ] Innovative
[ ) Repair [ ] Abandonment [ ) Temporary [ )
APPLICANT: Dave Pallas
AGENT: Dave Pallas TELEPHONE:
MAILING ADDRESS: 2361 Toolidge Rd Fort Pierce FL 34945
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 4.89.552, 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: 13 &14
BLOCK: 2
SUBDIVISION:
Totten Subdivision
PLATTED.
PROPERTY ID
#: 2417-704-0025-0008
ZONING:
I/M OR EQUIVALENT: [ YIN )
PROPERTY SIZE•: '0.21 ACRES WATER SUPPLY: [ X) PRIVATE PUBLIC [X )<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.00K5, FS? [ YIN ) DISTANCE TO SEWER: FT
PROPERTY ADDRESS, 2210 S: 40th Street
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [ J RESIDENTIAL [ X] COMMERCIAL
Unit Type of 'No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sgft Table 1, Chapter 64E-6*., FAC
1 Office Building 710
2
3
4
[ ) Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE: DATE:.
DH 4015, 08'/09 (Obsoletes previous- editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4 i