HomeMy WebLinkAboutApplication For Construction Permit 9-27-17(f
CI �E
o� STATE OF FLORIDA PERMIT NO.
DEPARTMENT OF HEALTH DATE PAID:
3 ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
;N SYSTEM RECEIPT #:
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[v/] New System [ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment [ ] Temporary [ ]
APPLICANT: Curtis and Jessica
AGENT:
MAILING ADDRESS: 5902 Hickory Drive, Fort Pierce, FL 34982-8601
TELEPHONE:
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: N/A BLOCK: N/A SUBDIVISION: N/A PLATTED: No
PROPERTY ID #: 4203-213-000410c)rp 3 ZONING: AG-5 I/M OR EQUIVALENT: [ No ]
PROPERTY SIZE: 2.99 ACRES WATER SUPPLY: [�/] PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ No ] DISTANCE TO SEWER: N/A FT
PROPERTY ADDRESS: TBD Carlton Road, Fort Pierce, FL 34987
DIRECTIONS TO PROPERTY: From Midway and SR-70 intersection, head west on SR-70 and turn south on Carlton road.
Continue down Carlton Road past bends to the east and south. Subject site is on the east site of the road.
BUILDING INFORMATION [v(] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
2-q72
1 Single Family -'S 21_ 400 GPD
2
3
4
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE:
DH 4015, 08/09 UCibsoletes previous editions which may not be used)
Incorporated 64 6.001, FAC
�gi1E
4b : STATE OF FLORIDA PERMIT # .
DEPARTMENT OF HEALTH
a ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
,N SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Curtis and Jessica Chancey AGENT:
LOT: N/A BLOCK: N/A SUBDIVISION: N/A
.PROPERTY ID # : Section 3/Township 37 South/4203-213-0004-3 [ Section/Township/Parcel No.
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE
PLAN: [✓]
YES [ ]
NO NET USABLE AREA AVAILABLE:
TOTAL ESTIMATED SEWAGE FLOW:
400GPD
GALLONS
PER DAY [RESIDENCES-TABLEI
AUTHORIZED SEWAGE FLOW:
1500
GALLONS
PER DAY [ 1500 GPD/ACRE
UNOBSTRUCTED AREA AVAILABLE:
3143+
SQFT
UNOBSTRUCTED AREA REQUIRED:
2.99 ACRES
l
1000 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Mag nail, edge of pavement, west of subject property.
ELEVATION OF PROPOSED SYSTEM SITE IS.12 [FT ] [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:100'+ FT NORMALLY WET? [ [ YES [✓] NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE:75+ FT NON —POTABLE: FT
BUILDING FOUNDATIONS:5'+ FT PROPERTY LINES:10'+ FT POTABLE WATER LINES: FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES (✓] NO 10 YEAR FLOODING? [ ] YES [✓] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
'-OBSERVED WATER TABLE: INCHES [ABOVE/BELOW '] EXISTING GRADE. TYPE: [PERCHED/ APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [.ABOVE/BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
DATE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 3 Of 4