HomeMy WebLinkAboutSewage Application For Construction Permita Re STATE OF FLORIDA PERMIT NO. &002,
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
SYSTEM RECEIPT
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
j ] New System Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment Temporary
[ ] Temporary [�/] PLAN REVIEW
APPLICANT:
MAILING ADDRESS : � ,5 0 � S P -f r a ,Y EPHO �p ( �?,51
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
APPLICANTfS 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':, �lp
SUBDIVISION:
lE�� �Ca PLATTED:
PROPERTY ID #7
12Sc)1 t//od'Ok01
9 /
ZONING: F I/M OR EQUIVALENT: [ Ye ]
PROPERTY SIZE:
�0- ACRES
WATER .SUPPLY:
[V] PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381•.0065, FS? [ Y/N ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: :1 15
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [ PRESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of
No Establishment Bedrooms
2• �J
3
4
Building Commercial/Institutional System Design
Ar�ea S�� gf�tTable 1., Chapter 64EK6, FAC
G /7 LISC) V ,
iEli-ai
[ I 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
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STATE OF FLORIDA PER":I T c
DEFART16£NT OF HEFiI.Tll
TR----
ONSIT£ SEWAGE EAT —ENT AND DISPOSAL SYSTEM
{ EXISTING SYSTEM AND SYSTEM REPAIR E%FALUA:ION
�•'4 �0 �i �ii • l ,
APPLICIANT
CONTRAUNT CTOR / A : -- `^ S - J (f r•- � .
[OT: SLOCK: SUBDIV: CY1V�Cr[LiZi��� ` IDt: ------
SO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTI-iENT E-"lPLOYEE, SEPTIC TANK,, CONTRACTOR OR
OTHER CERTIFIED PERSON_ SIGN AND SEAL ALL SUBP"?TTED DOCD•'.-r,NTS- CO_"X'!--TE ALL APPLICABLE I:'=_MS-
COMPLE?'E TANK CERTIFICATION BELOW OR NOTE TIN RE1 -RKS WBY TKE TANKS CANNOT BE CERTTFIED -
EX STIIIG TAY?---
9`GALLONS SEPTIC- WANK/GPD ATO LEGEND: _ ---- MATERLAL: ��-}3h� ,£D : (Y / N
�ONS SEPTIC TAN%/GPp ATU LEGEND: -- -- I�li3'ERT;_,:— --- B PEFLED: [fir /�
j GALLONS GRFASE INTERCEPTOR LEGEND: _ _ _ ; v,l ERIA-L :
(� ) GALIAHS DOSING TANK LEGEND: - 2�iTEP,Ir?,: - — — e PL7MPS
Y THAT THE LISTED TANIIS WERE
IDS SPE CIF I= D AS DETER!
�
OFi--,xKS , F*.'D H:,v-- A [
SIGRATURE OF JaICENSED CONTRACTOR
EXTSTTNG DRP 111FIELD IhMORMF.TION
6 �An I l BY i (2
LEGEND ] , ARE _ E OF 68SERVAIII.E
V r / OUTLET = ILTER DEVICE .) INSTALLED.
INESS WJ49 DATE
SQUARE FEET PR.1'•1MRY DRAIN•- IELD SYSTEM
NO. OF TRENCHES
( j DIMENSIONS:
g `U
� ) SQUARE r �E T S Y STEM
NO _ RENCEM SDIMENSIONS:—
[ J
'— — -- — —
TYPE OF SYSTEM: ( ) STANDARD [ ] FT-,..rD („/�p0
CONFIGURATION: [ ) TRENCH ( ] BED (
)
DESIGN: ( J 'DER ( J D-BOX r
J GRAVITY SYSTEM j J DOSED SYSTEM —
ELEVATION OF BOTTOM OF D_RAINFIELD I;7 RELATION TO E)ISTING GRADE
INCHES ( ABOVE
/ BELOW)
SYSTEM FAILURE PND REPAIR INFORMATION
�
[ ] SYSTE'4 INSTALLATION DATE
1
4PE OF WASTE
[.� ] '• -�I [ J
COMMERCIAL
( ) GPD ESTIVATED SEWAGE FLO-VT BASED ON
[ ) METERED
WATER [ ] TABLE 1,
64E- 6 , PAC
SITE I I DRAUQGE STRUCTURES ( J POOL { ) PATIO / DEC_K ( ) PARIam
CONDITIONS: ( ) SLOPING PROPERTY
RATUR.r OF { ) HYDRAULIC OVERLOAD
FAILURE: ( ] DRAIWe-E / RUN OFF
FA-TTLuRE [ I SEV.AGE ON GROUND
h
SYMPTOM: ( ) PLUMBING BACA-UP
[ ) SOILS [ ] x mTENANCE [ J SYSTEM DAMAGE
( ) ROOTS [ ] WAXER TABLE [' I
[ j TANY ( ] D BOX/HEADER [ ] DRAINFIELD
[ 1
SUBMITTED BY: _TITTLE/LICENSE �P ��L !/✓lC,� DATE: —t—
DIi 4015, 08/09 bsoletes previous editions vrhich may not bo us d)
Incorporated 64E-6.001, FAC Page 4 OE 4