HomeMy WebLinkAboutApplication For Construction PermitAPPLICATION FOR:
[ ] New _.System
[ ] Repair
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD-6., FAC
PERMIT # %-2/1I
DATE PAID
FEE PAID $ SO —
RECEIPT #
1,
j] Existing Systemm;. '[ ] Holding Tank [ ] Temporary/Experimental
[ ] Abandonment [ ] Other(Specify)
APPLICANT: ��'� .��✓�a/��S'7 �y�rJ TELEPHONE: oi.35(3
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AGENT: VOI %6 61-3 04 V731
MAILING ADDRESS: ® 60 y 0j;e Cz::
TO PE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SIy)E PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
i312QPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED], .
LOT: BLOCK: SUBDIVISION: DATE OF
SUBDIVISION:
PROPERTY ID #: [Section/Township/Range/Parcel No.] ZONING:
PROPERTY SIZE: �ACRES [Sgft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ PUBLIC'
PROPERTY STREETADDRESS:
L
DIRECTIONS TO PROPERTY:
IV
BUILDING INFORMATION [ ] RESIDENTIAL [Zj COMMERCIAL
Unit
Type of No. of
Building # Persons
Business Activity
No
Establishment Bedrooms
t
Area Saft Served
For Commercial Only
2
3
4
]
Garbage Grinders/Disposals,
[ ] Spas/Hot Tubs
[ ], Floor/Equipment Drains
[ ]
e
Ultra -low Volume Flush Toilets
[ ] Other (Specify)
d 99
APPLICANT'S
SIGNATURE:
DATE:
DH 4015, 10196 (Replaces HRS-H Form 4015 [Page 11 which may be used) Page 1 of 3
(Stock Number: 5744-001-4015-1)
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT; BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION:
Check type of permit, if "Other' specify type in blank.
Property owner's full name.
Telephone number for applicant or agent.
Property owner's legally authorized representative.
P.O. box or street, city, state and zip code mailing address for applicant or agent.
A
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot
legal description or deed must be attached.
Official date of subdivision recorded in county plat books (month/day/year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
PROPERTY ID#: 27 character number for property. (Health Department may require property appraiser ID# or section/township/range/parcel number.)
PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,S60 square feet) exclusive of all paved areas and prepared road
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or otJt
such bodies of water. Contiguous unpaved and noncompaeted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
Au �,
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed ,instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table 11, Chapter IOD-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure,
# PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table II, Chapter IOD-6, FAC.
FIXTURES: Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE. Signature of applicant or agent. Date application on day submitted to Health Department with appropriate fees and attachments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage+
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of wastewater.