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HomeMy WebLinkAboutApplication For Construction Permit�•{!lE SLR I " STATE OF FLORIDA PERMIT NO. SF-AL470 O DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND .DISPOSAL FEE PAID: }�SYSTEM RECEIPT #: � APPLICATION FOR CONSTRUCTION PERMIT APPLICATION FOR: [ ] New System [ ] Existing System [ ] Holding Tank [ ] Innovative [ ] Repair ([ ] Abandonment [ ] Temporary [ f ] Plan Review APPLICANT: �l Llr(eS T2 61' i..GWa.11C °l-7 -© Lb rn AGENT: f r TELEPHONE: MAILING ADDRESS: Q�t (l3 :G(� U i • -�+ �1 i C �C' L� t z q q � Z ----------------------------------------------------------- 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 �1 LOT: 5'L BLOCK: SUBDIVISION: es -me, of, PLATTED: PROPERTY ID•J&'132. '00 U-' XC)'C)ZONING: I/M OR EQUIVALENT: [ Y/N ] PROPERTY SIZE: ACRE WATER SUPPLY: [ ] PRIVATE PUBLIC [x]<=2000GPD [ 1>2000GPD IS SEWER AVAILABLE AS .PER 381.0065, FS? [ Y/N ] DISTANCE TO SEWER: FT PROPERTY ADDRESS: 16 �.7 f '' c L` (y>c:U gL- DIRECTIONS TO PROPERTY: BUILDING INFORMATION [ ] RESIDENTIAL [ ]'COMMERCIAL Unit Type of No, of Building Commercial/Institutional System Design No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC 1 S F �-- .� © tic)19 eZ4 vo o !23 eu a� 2 3 4 [ ] Floor/Equipment Drains [ ] Other (Specify) SIGNATURES ftX j`\y DATE: 3" I S " ZZ DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated 64E-6.001, FAC Page 1 of 4