HomeMy WebLinkAboutAPPLICATION FOR CONSTRUCTION PERMITE JUN ? 0
STATE OF FLORIDA PER-.01171MG
DEPARTMENT OF HEALTH Sr. Lucie County, F!
,p ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APP.LI.CATION FOR:
06 New $yetem
[ ] Repair
APPLICANT:
File copy
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT 4:
[ ] Existing System I ], Holding Tank [ ]
[X] Abandonment [ ] Temporary [ ]
AGENT: �Z��E�
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MAILING ADDRESS:
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TELEPHONE:
TO BE COMPLETED BY•APPLICANT OR APPLICANT'S AUTHORIZED A(;ENT. SYSTEMS MUST BE CONSTRUCTED
BY.A PERSON LICENSED`PURSUANT TO 469.1050)(m) OR 489.552, FLO1tIDA 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 INFORMA' ON 3& 5v
LOT: BtOCR: SUBDIVISION: PLATTED:
3A� 2- 1z3- 0c:)(Dl_ 0c,-0,`
PROPERTY ID #: ZONING:�S- I/M OR EQUIVALENT: [ Y
PROPERTY SIZE: ACRES WATER SUPPLY: [lam] PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GPD
� '30
IS SEWER AVAILABLE AS
// PE%R( 381.0065, FS? ([ Y /�J' DISTANCE TO SEWER: FT
PROPERTY ADDRESS: /S,
DIRECTIONS TO PROPERTY:�� `
BUILDING INFORMATION [] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No of Building Commercial/Institutional System Design
No Establishment Bedrooms Area.Sgft Table 1, Chapter 64E-6, F.AC.
1
2
3
4
[ ] Floor/Equipment Drains /[ ] Other
SIGNATURE: c 'Z�S74 t X � - ���1
DR 401.5, 08/09 (Obsole.tes P
Incorporated 64E-6.001, FAC
which may not be used)
DATE: Z CI
Page 1 of 4
6 `t3y/
APPLICANT'S NAME:
LEGAL DESCRIPTION: �,gs�L� C�,6��. z„ V2., wq.
I certify that there are no potable private wells within 75 feet of the available area for the
proposed septic system, that there are no non -potable wells within 50 feet of the available area
for the proposed septic system, that there are no wells within 25 feet of a pesticide -treated
building foundation, that there are no public wells that serve less than 25 people or less than 15
homes or businesses within 100 feet of the proposed septic 'system, that there are no public
wells that serve mQre than 25 people or more than 15 homes or businesses within 200 feet of
the proposed septic.. system, that the water line from the water meter or well to the structure is at
least 10 feet from the available area for the proposed septic system unless the plans show the
line to be double sleeved, that there is not a gravity sewer line, low pressure sewer line or
vacuum sewage line in a public easement or right-of-way that abuts the property, that there are
no lakes, streams, wetlands, or surface water within 75 feet of the available area for the
proposed septic system unless the property was created prior to 1972, that the septic system is
proposed on the side of the lot farthest from surface water, that all private wells, septic systems
and surface water on adjacent or contiguous land within 75 feet of the applicant's lot are shown
on the site plan, that all public wells within 200 feet of the applicant's lot are shown on the site
plan, and that the location of building or residences, swimming pools, recorded easements,
paved areas or driveways, sidewalks, the general slope of the property, filled areas, drainage
features, and surface waters such as lakes, ponds, streams, canals, or wetlands are shown on the
applicants lot.
The natural grade elevation in the area of the proposed septic system and the benchmark must
be shown on the site plan. Please locate the benchmark within 200 feet of the proposed septic
System.
•+A
NOTE: - MUST BE CERTIFIED BY A FLORIDA
REGISTERED SURVEYOR OR ENGINEER
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