HomeMy WebLinkAboutApplication For Construction New System`.#APPLICAT-iON FOR:
,New System
[ ] Repair
STATE OF FLORIDA PERMIT
DEPARTMENT OF HEALTH DATE PAID C?S
ONSITE SEWAGE DISPOSAL SYSTEM ., .PA71p. $ ql6 % 6-0
APPLICATION FOR CONSTRUCTION PERMIT. RECEIPT ,}
Authority: Chapter-381, FS & Chapter 1OD-6, PAC
[ ] Existing System [ ] Holding Tank [ ] Temporary/Experimental
[ ) Abandonment [ ] Other(Specify)
APPLICANT:r
AGENT:
MAILING ADDRESS:
TELEPHONE: ' f�,�
El
TO Be COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE'PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN.A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: SUBDIVISION: DATE OF
SUBDIVISION:
PROPERTY ID #:/ `IA2 �OoC-nno '3[Section/Township/Range/Parcel No.) ZONING:
PROPERTY SIZEs,2,?! ACRES [Sgft/43560] PROPERTY WATER SUPPLY: D< PRIVATE [ ) PUBLIC
_ r►
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY' -
BUILDING INFORMATION
[ RESIDENTIAL
[ ] COMMERCIAL
Unit
Type of
No. of
Building # Persons Business Activity .
No
Establishment.
Bedrooms
Area Soft Served For Commercial Only
1
51 Nt, Lis FAM (L
2
3
• 4
1941`Garbage Grinders/Disposals [ ] Spas/Hot Tubs [ ] Floor/Equipment Drains
[ ] Ultra -low Volume Flush Toilets [ ]Other (Specify)
APPLICANT'S SIGNATURE: DATE: D�
e 1 r OH 4015, 10/95 (Replaces HRS-H Form 4015 [Page 11 which may be used) Page
(Stock Number: 5744-001-4015-1)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
�H SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Dale / WC
AGENT:-aBLOOMSTER PLS
LOT: BLOCK:
Custom Homes
SUBDIVISION:
CENTRAX #: 56-SF-08964
OSTDSNBR : 06-0337-N
TO BE COMPLETED BY ENGINEER,
MUST PROVIDE REGISTRATION NUMBER
HEALTH DEPARTMENT EMPLOYEE,
AND SIGN AND EEAL FACH PACE
OR OTHER QUALIFIED PERSON. ENGINEER'S'
OF STTRMTTTAT OMPT FTF AT T T MS
PROPERTY SIZE CONFORMS TO SITE PLAN: [XI YES [ ]NO
NET
USABLE AREA AVAILABLE: 2.30 ACRES'
TOTAL ESTIMATED SEWAGE FLOW:
500 GALLONS
PER DAY
[64E-6, TABLE 11
AUTHORIZED SEWAGE FLOW:
3450 GALLONS
PER DAY
[1500GPD/ACRE OR 2500GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE:
2000 SQFT
UNOBSTRUCTED AREA REQUIRED: 1250 SQE
BENCHMARK/REFERENCE POINT LOCATION: Nail In East Side of Road Near South Property Line
ELEVATION OF PROPOSED SYSTEM SITE IS 46.00 [ INCHES ] [ ABOVE ]BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: 100. FT DITCHES/SWALES: 15 FT NORMALLY WET? [ ]YES [ X NO
WELLS:.PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: 75+ FT NON -POTABLE: N/A FT
BUILDING FOUNDATIONS: 5+ FT PROPERTY LINES: 10 FT POTABLE WATER LINES: N/A FT
SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO 10 YEAR FLOODING? [ ]YES [ X ]NO
10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD SITE ELEVATION:' 0 FT NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell #/Color Texture Depth
9nyR-4/2-n a RN F;na Cand n to a
1022-5/1-RN Sand g to 3n
_1_QYR-F/3-R RN Rand 10 t0 4R
1nyR-S/6-v AN Cand 4A to 72
t0
to
}- n
to.
USDA SOIL SERIES: 53 Welaka Varia
SOIL PROFILE INFORMATION SITE 2
Munsell #/Color Texture Depth
1 nvR-4/2-n a RN Fj ne. Sand n to
innVR-9/1-1;N Cand to 1n
1oYR-sf�-n RN Rand 3n t0 4Q.:
7nyR-4/9-y RN Sand 4A t0
t0
t0
to
t0
USDA SOIL SERIES: 53 Welaka Varia
OBSERVED WATER TABLE: 80.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION:80.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
aSOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:Sand/0.80 DEPTH OF EXCAVATION: 0.0
DRAINFIELD CONFIGURATION: [ ]TRENCH [.X ]BED [ ]OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
,estimated WSWT determined from USDA Soil Conservation Svc soil survey of SLC & existing
BDF elevations of surrounding properties.
SITE EVALUATED BY: JOHN HANSON
DH 4015, G3/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-003-4015-1) [ostds_eval_4015-3]
DATE:
ON
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