HomeMy WebLinkAboutSewage Application For Construction PermitSTATE OF FLORIDA
DEPARTMENT OF HEALTH
p ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
PERMIT NO..'�C-AJQLAJj
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair I l Abandonment [ ] Temporary [ �/ ] Plan Review
APPLICANT:
AGENT:
MAILING ADDRESS:
TELEPHONE:( 1' �) U 5L) - 0 6 8
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
n r--.1 k
LOT: � BLOCK: SUBDIVISION: b� 'UJ-zj cof PLATTED:
PROPERTY ID #: b I r b _� �� iI ZON N�G: I/M OR EQUIVALENT: [ Y/N ]
PROPERTY SIZE: �� ACRES WATER SUPPLY: [15d] PRIVATE PUBLIC [ ]<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ N ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
2
3
4
' rL a� q 5 i
[ RESIDENTIAL [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E=6, FAC
am -
91 OLI
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE:
DR 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
DATE: ' 3 J "q I
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