HomeMy WebLinkAboutAPPLICATION FOR CONSTRUCTION PERMITAPPLICATION FOR:
[ ] New System
[ ] Repair
APPLICANT:
AGENT: ale
MAILING ADDRESS:
STATE OF FLORIDA,
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL S
APPLICATION FOR CONSTRUC
Authority: Chapter 381,
- I ?„
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[ �] Existing System
[ J Abandonment
SCANNED
c BY
ON PERMIT
S & Chapter 1OD-6, FAC
t,
] Holding Tank
] Other(Specify)
PERMIT #
I, / r
DATE PAID
FEE PAID
RECEIPT #
[ ] Temporary/Experimental
TELEPHONE:
TO BE COMPLETED BY APPLICANT;OR"'APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUI D BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
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PROPERTY INFORMATION [IF LOT IS NOT IN A____RE;ORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: '_5�411
p BLOCK: SUBDIVISION:
PROPERTY ID #: U 4 -ono t -6o® & [
PROPERTY SIZE: ,n ��ACRES [Sgft/43560]
PROPERTY STREET �ADD CRESS: � D
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [ ] RESIDENTIAL
Unit Type of No. of
No Establishment ° Bedrooms
2
-3
4
)-Garbage Grinders/Disposals
[ ]'Ultra -low Volume Flush; Toi
APPLICANT'S SIGNATURE:
DATE OF
SUBDIVISION:
ion/Township/Range/Parcel No.] ZONING:
PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
[ ] COMMERCIAL
# Persons Business Activity
Served For Commercial Only
r
I
I
i
[f ]1�1Spas/Hot Tubs
zts [ ] Other (Specify)
i
[ ] Floor/Equipment Drains
10.1
DATE:
i
DH 4015, 1.0/96 (Replaces HRS-H Form 4015 [Page 11 which may be used) I
(Stock Number: 5744-001-4015-1)
Page 1 of 3
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION:
PROPERTY ID#:
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.
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.
27 character number for property. (Health Department may require property appraiser ID# or section/townshipirange/parcel number.)
PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,560 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 other
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.
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 II, 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 I1, 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 playa showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of wastewater.