HomeMy WebLinkAboutAPPLICATION FOR CONSTRUCTION PERMITI
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& STATE OF FLORIDA PERMIT NO. I$3 3
F DEPARTMENT OF HEALTH DATE PAID:
' ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
SYSTEM i RECEIPT #:
APPLICATION FOR CONSTRUCTION PERMIT,
APPLICATION FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] ovative
[ ] Repair [ ] Aban onment I [ ] Temporary ["T Plow 4'a'Ou
APPLICANT:
'�Ul
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AGENT: TELEPHONE : Q �b
MAILING ADDRESS:'
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
LOT: 3 BLOCK: lOZ SUBDIVISION: ���C(,(}�QQ �Ci /� PLATTED:
PROPERTY ID #: 1AD1 -LD U
PROPERTY SIZE: ACRES WATER
IS SEWER AVAILABLE AS PER 381.0065,
PROPERTY ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1 . 5-r—K-
2
3
4
ZONING: I/M OR EQUIVALENT: [ Y / N ]
PLY: [ PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000GPD
? f Y / DISTANCE TO SEWER: FT
P=ral
[ �SIDENTIAL• [ ] COMMERCIAL
No. of! Building Commercial/Institutional System Design,
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
3L 15-go
-' N O � QGQ{�1�M �LG• n� AG�C�o�
[ ] Toor/E ipment,,Drains [ ] Other •(Specify)
SI
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
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DATE: '5150
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