HomeMy WebLinkAboutApplication For Construction PermitSTATE OF FLORIDA
<. DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
` AppAPPLICATION FOR CONSTRUCTION PERMIT
PERMIT NO.:! r-
DATE PAID:
FEE PAID: > r
RECEIPT #: �_JL-: A
APPLICATION FOR:
[. ] New System [ ✓ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair ` 1 [ ] Abandonment [L ] Temporary [ ]
APPLICANT: ✓��V_
AGENT: �tTL�i-�71.- VGG..�jt �t.✓�t-Ca-� C ,Jn s..Jmr5TELEPHONE:1772 )101- '12
MAILING ADDRESS: 7 D C-90.,^ �/ ,,V e_: r t f'o ra' tq; e'er
TO BE COLLETED 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: J SUBDIVISION: 6",k O (r PLATTED:
PROPERTY ID # : Z 3u f 3 ` t O 00 k - 0 V `ZONING: 6� LUL4f-4*;:C I/M OR EQUIVALENT: a,
N ]
CA Lle^
PROPERTY SIZE: 9-AP ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [>']<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ YIN ] DISTANCE TO SEWER: FT
el -
PROPERTY ADDRESS: S (/k-S R IJ ` /n�-- f Q C� P 1 •trG,/ G
DIRECTIONSTOPROPERTY: �, A ela 5 y M� c✓1 ,r r fig✓� (/` �-
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) ,,�•
O
DATE:
SIGNATURE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, PAC Page 1 of 4