HomeMy WebLinkAbout99090081FROM : GRLE/VERO PHONE 0. 407+419+6758
BY
� � �E�Cie(en�tnfi
GALE INS LATION
3490 OL' EAN ER AVENUE
FT. PIERC , FL 34982
(561)- 65-9191
CERTIFICATION, OF INSULATION
R- I I INSULATION INSTALLED IN GARAGE COMMON WALL
R 11 INSULATION INSTALLED INJ EXTERIOR WALLS
R — 30 INSULATION INSTALLED CEILING AREAS
LEGAL: Lot 28 Wide 'Waters
PERMIT:-,�990000ti" siz'i
ADDRESS: 3335'Perimeter Road
BUILDER: First Florida
DATE OF COMPLETION: I I
E
Nov. 24 1999 04:48PM P1
STATE OF FLORIDA, COUNTY OF ST_ LUCIE, THE FORE G 1NSTR NT WAS
ACKNOWLEDGED BEFORE ME THIS � „DAY OF 1999, BY
RUSSELL SOBCZAK, WHO IS PERIE, ALLY KNOWN TO ME.
N Y LIC: STATE OF FLORIDA
' d,�+� � Kathy Cornell* *My COmmissfan CC7 6727
3�ry��,',+,� gybes April aa, 2aa Clem
ltcciNe
2 9 1999
.unty Public Works
FORM 600A-97
- FLORIDA ENER Y EFFICIENCY CODE-zArm
FOR BUILDIN CONSTRUCTION
Florida Departm ant of Community Affairs StLudeCountv
Residential Whole Bu Iding Performance Method A
Project Name: RATTLESNAKE POINT 00.911 Builder:
Address: Permitting Office:
City, State: MARTIN CO., FL Permit Number:
Owner: JOHNSON Jurisdiction Number:
Climate Zone: South
1. New construction or existing New
_
12. Cooling systerns
2. Single family or multi -family Single fancily
_
a. Central Unit Cap: 38.4 kBtu/hr _
3. Number of units, if multi -family 1
_
SEER: 11.00 _
4. Number of Bedrooms 2
_
b. NIA
5. Is this a worst case'? No
6- Conditioned floor area (ft') 1598 ft'
c. N/A _
7. Glass area & type
a. Clear - single paac 0.0 ftl
13. Heating systems
b. Clear - double pane 0.0 ft'
_
a. Electric Strip Cap: 38.4 kBtu/hr
c. Tint/other SC/SHGC - single pane 322.1 tt'
_
I COP: 1,00 _
d. Tint/other SC/SHGC - double pane 0.0112
b. N/A _
S. Floor types
a. Slab -On -Grade Edge Insulation. R-0.0, 204.3(p) ft
_
c. N/A _
b. N/A
c. N/A
14. Hot water systems
9. Wall types
_
a. Electric Resistance Cap: 50.0 gallons _
s. Frame, Wood, Exterior R=11.0,1054.7 ft'
_
I EF: 0.88 _
b. Frame, Wood, Adjacent R-11.0, 380.4 fF
_
b. NIA _
c. NIA
d. NIA
_
o. Consemation. credits _
e. NIA
(HR•Heat recovery, Solar
10. Ceiling types
_
DlP-Aediested .heat pump)
a. Under Attic lZ 19.0,1543.0 ft'
_
15. HVAC credits _
b. Single Assembly R=19.0,165.0 ft'
_
(CF-Ceilingg fan, CV -Cross vciatilation,.
c. N/A
HF-W ole house fart,
11. Ducts
_
PT -Programmable Thermostat,
a. Sup: Con. Ret: Con. AH: Anterior Sup. R=6.0, 50.0 ft
_
XB-Attic radiant batTier,
b. N/A
MZ-C-Multiaone. cooling,
MZ-H-Multiaone heating)
Glass/Floor Area: 0.20 Total as-b
ilt points: 3.00 PASS g�
Total, ba
a points: 2237373.00
I hereby certify that the plans and specifications coven
-by this calculation are in compliance with the Florida
Energy Code.
PREPARED BYFARTH SMART 5 - 86-561
DATE: „Z)0 &a fff - 194
1 hereby certify that this uilding, as designed, is in
compliance with the Florida Energy Code.
OWNER/AGENT:
DATE:
Review of the plans and za$sT
specifications covered by this
calculation indicates compliance
with the Florida Energy Code.
Before constriction is completed
this building will be inspected for n
compliance with Section 553.908
Florida Statutes.
BUILDING OFFICIAL:
DATE:
(Version: FLRCNA-200)
SCANMW
FORM 600A-97 BY
st Lucie ColuntV
SUMMER CALCULATIONS
Residential Whole Building Performance Method A - Details
ADDRESS:. MARTIN CO., FL, I PERMIT #: I
BASE
AS -BUILT
GLASS TYPES
.18 X Conditioned X BSPM = Points
Overhang
Floor Area
Type/SI
Ornt
Len
Hgt
Area
X SPM X
SOF
= Points
.18 1598.0 63.20 16303.2
Single, T
nt
S
1.6
6.6
16.0
52.00
0.88
735.7
Single, T
nt
SE
1.0
8.6
14.2
62.23
1.00
882.4
Single, T
nt
SE
1.0
1210
23.2
62.23
1.00
1442.4
Single, T
nt
NE
1.0
12.0
66.0
42.92
1.00
2395.7
Single, T
nt
NE
1.6
8.0
56.0
42.92
0.95
2292.4
Single, T
nt
N
1.6
8.0
56.0
27.68
0.96
1481,6
Single, T
nt
N
6.6
7.6
5313
27.68
0.77
1131 T
Single, Tlnt
N
1.0
6.6
23.2
27.68
0.98
630.5
Single, Tilt
NW
1.0
7.6
14.2
37.22
0.99
52316
Single, Ti
it
NW
1.0
10.0
5.0
37.22
1.00
185.4
Single, Tit
SW
1,0
10.0
5.0
57.13
1.00
284.9
As -Built
'otall:
3221
11996.2
WALL TYPES
Area X BSPM = Points
Type
R-Value
Area X
SPM
= Points
Adajoent
380.4 1.0
380.4
Frame,
ood, Exterior
11.0
1054.7
2.70
2847.7
Exterior
1054.7 2.70
2647.7
Frame,
00d, Adjacent
11.0
380.4
1.00
380.4
Base Total:
1435.1
3223.1
As -Built
otai:
1435.1
3228.1
DOOR TYPES
Area X BSPM =
Points
Type
Area X
SPM
= Points
Adjacent
18.0 2.60
46.8
Ealerior Wood
40.0
0.40
376.0
exterior
40.0 e.40
255.0
Adjacent
Trod
13.0
3.80
68.4
Base Total:
58.0
302.8
As -Built Total:
58.0
444A
CEILING TYPES
Area X BSPM =
Points
Type
R-Value
Area X
SPM
= Points
Under Attic
1598.0 0.80
1278.4
UnderAtti
19.0
1543.0
1.50
2314.5
Single A
embly
19.0
165.0
2.50
412.5
Base Total:
1598.0
1278.4
As -Built
otal:
1708.0
2727.0
FLOOR TYPES
Area X BSPM =
Points
Type
R-Value
Area X
SPM =
Points
Slab
204.3(p) -20.0
-4086.0
Slab -On-
rade Edge Insulation
0.0
204.3(p) -20.00
-4086.0
Raised
0,0 0.00
0.0
Base Total:
-4088.0
As -Built Ti
tal;
-4086.0
INFILTRATION
Area X BSPM =
Paints
Area X
SPM =
Points
1598.0 16.79
30026.4
1598.0
18.79
30026.4
EnergyGauget DCA Form 60OA-91 EnergyGauge(&/ IaRES'97 FLRCNA-200
ED
FORM GOOK-9-By ,
St Ludsftfltv SUMMER
Residential Whole Buildi
LCULATIONS
Performance Method A - Details
I ADDRESS', MARTIN CO., PL, I PERMIT #. I
BASE
AS -BUILD'
Summer Base Points:
46062.9
Summer
As -Built Points:
44336.2
Total Summer X System
= Cooling
Total
X Cap X Duct X
System
X Credit
= Cooling
Points Multiplier
Points
Comp?vent
Ratio Multiplier
Multiplier
Multiplier
Points
443�6.2
1.000 0.930
0.310
1.000
12782.1
46052.9 0.3560
16394.8
44336.2
1.00 0.930
0.310
1.000
12782.1
EnergyGaugeTm DCA Form 60OA-97 EnergyGau§a0/ 1aRES'97 FLRCNA-200
FORM-60OA-97 SCANNED
BY
St Lucie CoNVONTER ALCULATIONS
Residential Whole Building Performance Method A - Details
ADDRESS:, MARTIN CO., FL,
PERMIT #:
BASE
AS -GUILT
GLASS TYPES
.18 X Conditioned X BWPM =
Points
Overhang
Floor Area
Type1SC
Ornt
Len
Hgt
Area X
WPM X
WOF =
Points
.18 1698.0
2.02
632.3
Single,
int
s
1.6
6.6
16.0
3.80
1.02
61.9
Single,
ant
SE
1.0
8.6
14.2
3.58
1.02
51.7
Single,
int
SE
1.0
12.0
Y3.2
3.58
1.01
84.1
Single,
int
NE
1.0
12.0
56.0
4.81
1.00
269.0
Single,
Tint
NE
1.6
8.0
56.0
4.81
1.00
268.7
Single,
Tint
N
1.6
8.0
56.0
4.98
0.99
277.3
Single,
Tint
N
5.6
7.6
53.3
4.98
0.97
258.1
Single,
Tint
N
1.0
6.6
23.2
4.98
1,00
115.1
Single,
Tint
NW
1.0
7.6
14.2
4.95
1.00
70.1
Single,
Tint
NW
1.0
10.0
6.0
4.95
1.00
24.7
Single.
Tint
SW
1.0
10.0
5.0
4.27
1.00
21.3
As-Bu
It Total:
322.1
1602.1
WALL TYPES
Area X BWPM
= Points
Type
R-value
Area X
WPM =
Points
Adejoent
380.4
0.5
190.2
Frame
Wood, Exterior
11.0
1054.7
0.60
632.8
Exterior
1054.7
0.60
632.8
Frame
Wood, Adjacent
11.0
$60.4
0.50
190,2
Base Total.
1435.1
823.0
As -Built
Total:
1435.1
823.0
DOOR TYPES
Area X BWPM
= Points
Typel
Area X
WPM =
Points
Adjacent
16.0
1.30
23.4
Exterior
Wood
40.0
2.80
112.0
Exterior
40.0
1.80
72.0
Adjac
nt Wood
18.0
1.90
34.2
Base Total:
58.0
95.4
As-Bulllt
Total:
58.0
446.2
CEILING TYPES Area X
BWPM = Points
Typel
R-Value
Area X
WPM =
Points
Under Attic
1598.0
0.10
159.8
Undei
Attic
19.0
1543.0
030
462.9
Singl
Assembly
19.0
165.0
0.30
49.5
Base Total:
1598.0
150.8
As -St
lit
1708.0
612.4
FLOOR TYPES
Area X
BWPh1 = Points
Type
R-Value
Area X
WPM W
Points
Slab
204.3(p)
-2.1
-429.0
Slab-8n-Grade
Edge Insulation
0.0
204.3(p)
-2.10
-429.0
Raised
0.0
0.00
0.0
Base Total:
-429.0
As -Built
Total.
-429.0
INFILTRATION
Area X BWPM
= Points
Area X
WPM =
Points
1598.0
-0.08
-96.9
I
1598.0
-0.06
-95.9
EnergyGaugeO OCA Form 600A-97 En
FLRCNA-200
SCANNED
FORM 600A-97 BY
tLu . '� f-UT"'E'R CALCULATIONS
Residential Whole Buildingl Performance Method A - Details
I ADDRF-$$: , MARTIN CO., FL, I PERMIT #: l
BASE
AS -BUILT
Winter Base Points:
1135.6
Winter As -Built Points:
2458.8
Total Winter X System -
Points Multiplier
Heating
Points
Total X Cap X Duct X
Component Ratio Multiplier
System X
Multiplier
Credit =
Multiplier
Heating
Points
1135.6 1.0900
1237.8
245�.8
245P.8
1.000 0.930
1.00 0.930
1.000
1.000
1.000
1.000
2286.7
2286.7
EnergyGaugeT" DCA Form 60OA-97 EnergyGauOVIFIaRES'97 FLRCNA-200
SCANNED
FORM BOOA-97 BY
V1i'�►TER'i ��ffWb C i ®� Gt�MPLIANCE STATUS
Residential Whole Building Performance Method A - Details
ADDRESS: , MARTIN CO., FL,
PERMIT #:
BASE
AS -BUILT
WATER HEATING
Number of X Multiplier = Total
Tank
EF Number of X Tank X Multiplier X Credit = Total
Bedrooms
Volurn
Bedrooms Ratio Multiplier
2 2370.00 4740.0
50.0
0.88 2 1.00 2389.00 1.00 4738.0
As-BuiltTotal:
4738.0
CODE COMPLIANCE
STATUS
BASE
AS -BUILT
Cooling + Heating + Hot Water = Tota
Points Points Points Point
Cooling + Heating + Hot Water = Total
Points Points Points Points
16394.3 1237.8 4740.0 223
2.7
1 12782.1 2286.7 4738.0 19806.8
EnergyGauge`" DCA Form 600A•97
FORM !800A-97 BY
bode Compliance Checklist
Residential Whole Building Performance Method A - Details
ADDRESS;, MARTIN CO., FL, PERMIT A:
6A-21 INFILTRATION REDUCTION COMPLIANCE HECKLIST
Exterior Windows & Doors
606.1 ABC.1.1 I
Maximum:.3 cfnVso.ft.
window area; .5 cfm/sq.tt. door area.
Exterior & Adjacent Walls
606.1 ABG.1,2.t ,
Caulk, gasket,
atherstrip or seal between: windowsidoore & frames, surrounding wall;
behveen at corners: utillty
foundation & wIll
sole or sill plate; Joints exterior wall panels
penetrations;
b tween wall panels & top/bottom plates; between walls and floor.
EXCEPTION;
rams walls whore a continuous infiltration barrier is installed that extends
l
from and is sealed
to the foundatlon to the top Riate.
Floors
606.1.ABC.1.2.2
Penetrations
enings >l r8" sealed unless backed by truss orjoint members.
EXCEPTION:
(gIame floors where a continuous infiltration barrier is installed that is sealed
to the erlmatek
enetr dons and seams.
Ceilings
Between walls
ceilings; penetrations of ceiling plane of top floor: around shafts, chases,
1606A.ABC.1.2.3
soffits, chimne
s, cabinets sealed to Continuous air barrier; gaps in gyp board & top plate;
attic access. E
CEPTION: Fraina ceilings where a continuous infiltration barrier is
Installed that 1
sealed at the perimeter, at enetration$ and seams.
Recessed Lighting Fixtures
606.1.ABC.1.2.4
Type IC rated
ith no penetrations, sealed; or Type IG or non -IC rated, Installed Inside a
sealed box wittl/2"
clearance & 3" from insulation; or Type IC rated with < 2.0 cfm from
Multi -story Houses 606.1.ABG.1 2.5 I Air barr;er on rirneter of floor Cavity between Mors.
Additional Infiltration refits I 606.1.A.BC.1.3 I Exhaust fans qentoo to outdoors, dampers; combustion space heaters comply with NFPA,
w■ ww ��rree-. nrfrn�rrnTt10 ONO 01 MCC 1.w #I hd m # nr n AAAOPi k 9111malrlant-isa i
COMPONENTS
SECTION
REQUIREMENTS
CHECK
Water Heaters
6121
Comply with
. iciency requirements in Table 6.12, Switch or clearly marked circuit
breaker elect
iG or cutoff gasmust be provided. External or built-in heat trap required.
Swimming Pools & Spas
612.1
Spas & heate
I pools must have covers (except solar heated). Non-commercial pools
must have a r
ump timer. Gas spa & pooi heaters must have a minimum thermal
efficiency of 7
9%.
Shower heads
512.1
Water flow m
ist be restricted to no more then 2.5 ciallons per minute at 80 PSIG.
Air Distribution Systems
i 610.1
All ducts, fifth
gs, mechanical equipment and plenum chambers shall be mechanically
attached, se led,
insulated, and installed In accordance with the criteria of Section 610.
Ducts In unconditioned
attics: R-6 min. insulation. _
H'JAC Controls
607.1
Se arate rea
ily accessible manual or automatic thermostat for each system.
Insulation
604.1, 602.1
Ceilings -Min.
R-19. Common wells -Frame R-11 or CBS R-3 both sides. j
Common cal Ing
& floors R-11.
EnergyGaugeT1' DCA Form 60OA•97
FLRCNA-200
SCANNLU
`4 E�
PERFORMANCE ANCE LEVEL (EFL)
DISPLAY CARD
ESTIMATED ENERGY ERFORMANCE SCORE* = 85.2
The higher the scot , the more efficient the home.
1. New construction or existing
2. Single family or multi -family
3, Number of waits, if multi -family
4. Number of Bedrooms
5. Is this a worst case?
6. Conditioned floor area (£t')
7. Glass area & 15,pe
a. Clear - single pane
b. Clear - double pane
c. Txntlother SCISHrjC - single pane
d. Tintlother SCISHGC. - double pane
8. Floor types
a. Slab -On -Grade Edge Insulation
b. NIA
c. NIA
9. Wall types
a. Fr2me, Wood, Exterior
b. Frame, Wood, Adjacent
c. NIA
d. N/A
e. NIA
10. Ceiling types
a. Under Attic
b. Single Assembly
c. NIA
11. Dact5
a. Sup: Con. Rct: Con. Ail: laterior
b. NIA
JOHNSON
New
Single family
1
2
No
1598 ft'
0.0 ft,
0.092
322.1 f1'
0.0 fl'
R=0.0, 2043(p) ft
R=11.0, 1054.7 W
R=l 1.0, 380.4 ft'
1, MARTIN CO., FL,
PL-19.0, 1543.0
R=19.0, 165.0 ft _
I —
Sup. R=6.0, 50.0
12. Cooling %ysterns
a. Central Unit
b. NIA
c. NIA
13. Hrating systems
a Electric Strip
b. N/A
c, NIA
14, Hot water systems
a. Electric Resistance
b. NIA
c. Conservation credits
(HR-Heat recovery, Solar
DHP-Dedicated beat pump)
15. HVAC credits
(CF-Ceiling fan, CV -Cross ventilation,
I-F,Whole house fan,
PT -Programmable Thermostat,
RB-Attic radiant barrier,
MZ-C-'Multizone cooling,
MZ•H-Multizone heating)
I certify that this home has complied with the Florida Energy g Efficiency Code For Building
Construction through the above energy saving features wbich will be installed (or exceeded)
in this home before final inspection. Otherwise, a new EP��LLL,,„Iliii Display Card will be completed
based on installed Code compliant features.
Builder Signature,
Address of New Home:
4WOZE. The home's estimated energy performance score
This is not a Building ,Energy Rating. If your score is 80 o
your home may qualify for energy efficiency mortgage (E)
Contact the Energy Gauge Hotline at 401-1638-1492 or se
information and a list of certified .Raters. For information
contact the Department of Community Affairs at 850/487-
Date:
City/FL Zip:
Cap: 38.4 kBW tr _
SEER11-00 _
Cap: 38.4 k13tu+hr _
COP: 1.00 _
Cap: 50.0 gallons _
EF: 0.88 _
is only available through the FLARES computer7Mprogram.
r greater (or 86 for a US ,EPA/DOE ,E'nerg yStar designation),
+iM) incentives if you obtain a Florida Enerlp, Gauge Rating.
b the Energy Gauge web site at wwwfsec. uef edu for
about Florida's .Energy Efficiency Code For Building Construction,
�1824.
(Versiou: FLRCNA 200)
DEP
SCANNED
!BY
St Lude CwhDESIGN CERTIFICAT
ST. LUCIE COUNTY
'T OF COMMUNITY DEVELOPMENT
2300 VIRGINIA AVENUE
FT. PIERCE, FL. 34982-5652
561-462-1553
N FOR WIND LOAD COMPLIANCE
This Certification is to be completed by the project design architect or engineer. This CanificaWn must be submitted with all applicatlons
for building permit involving the construction of new residency (single or multi -family), residential addition, any accessory structure requiring
a building permit, and any nonresidential structure. This Certification shall not apply to interior renovations (provided that no structural
walla, columns or other similer Component is being effected) Ind certain other minor building permits. For further assistance., please contact
the BulldinQ lns;�ection Office at 462-1553 or 462-2172.
II PROJECT NAME (Jb I4lJtioill 5'^ "`i !^K''r ice+ Y• ': ` i" -. ; '; QFFiCE•tJ9i;`ONCY:' .............
PR NUMBER
PERMIT NUN
OCCP. TYPE
CST. TYPE
CERTIFICATION STATEMENT:
I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, THESE PLANS AND SPECIFICATIONS HAVE
BEEN DESIGNED TO COMPLY WITH THE APP (CABLE STRUCTURAL PORTION OF THE BUILDING CODES
CURRENTLY ADOPTED AND ENFORCED BY ST. LUCIE COUNTY. I ALSO CERTIFY THAT STRUCTURAL ELEMENTS
DEPICTED ON THESE PLANS PROVIDE ADEQUA�E RESISTANCE TO THE WIND LOADS AND FORCES SPECIFIED
BY CURRENT CODE PROVISIONS,
1. STANDARD BUILDING CODE 1997 EDITION —A
2. BUILDING DESIGN IS (CHECK 00a) ENCLOSED
3. BUILDING HEIGHT: Of FT
S. WIND EXPOSURE CLASSIFICATION (REFER To EXPO:
6. AVERAGE WIND VELOCITY PRESSURE ON EXTER
T. PEAK WIND VELOCITY PRESSURE ON EXTERIOR I
a. IMPORTANCE/USE FACTOR (OBTAIN FROM BUILDING C
S. LOADS: FLOOR PSF ROOFIDEAD:
10. WERE SHEAR WALLS CONSIDERED FOR STRUCTI
explalnatlon)
11. IS A CONTINUOUS LOAD PATH PROVIDED (CHECK c
12. ARE COMPONENT AND CLADDING DETAILS PROM
explaination)
13. MINIMUM SOIL BEARING PRESSURE: 9,
AS WITNESSED BY MY SEAL, I HEREBY CERTIFY
IS TRUE AND CORRECT, TO THE BEST OF MY k
NAME: M• WWt-, CERTIFICAI
DESIGN FIRM: Aa.AZVP-WNM DA'
141"101014-
ASCE 7-95 OTHER (SPECIFY)
PARTIALLY ENCLOSED
OPEN BUILDING
4. WIND SPEED USED IN BUILDING DESIGN:
MPH'
t�t
T/18Lk5 IN BUILDING CODE IDENTIFIED IN UNI6
91):
FACES OF STRUCTURE:_
PSF
:-S OF STRUCTURE:
PSF
PSF
ROORLIVE: 3O PSF
(CHECK ONE; YES �
NO_ If NO. why? (attach
YES NO
If NO, why? (attach explainatlon)
I (CHECK ONE) YES
NO _ If NO, why? (attach
_ PSF
HAT THE INFORMATION INCLUDED WITH THISCERTIFICATION
OWLEDGE AND BELIEF.
IN N0: /u—'v,I4
• 9 [SEAL HERE]
ELCCOV FORM NO: 0200
ST. LUCIE COUNTY HEALTH DEPARTMENT
• SCANNED FLORIDA DEPARTMENT OF
St Lucie Countv HEALT
Jeb Bush Robert G. Brooks, M.D.
Governor Secretary
September 3, 1999
First Florida Development and Construction, Inc.
Ms. Margo Brinsley
200 NE Dixie Highway
Stuart, FL 34994
Dear Ms. Brinsley:
This letter is to notify you the Department has rec
septic. system approval located at 3335 Perimeter
Lucie County.
On September 2, personnel from this office condu
be operating in what appeared to be a satisfactory
hazards were noted at the time of inspection.
It is our understanding you are proposing to enclo
objections to this proposed construction.
Should a sanitary nuisance/public health violation
will be required to obtain the necessary permit(s) ;
compliance.
THIS APPROVAL DOES NOT GUARANTEE P.
AND IS VALID FOR A PERIOD NOT EXCEED
DATE.
If you have any questions concerning this matter,
Sincerely,
A
C
J.C. Dunca
Environmental Specialist II
and reviewed your request for an existing
in the Wide Waters subdivision of St.
a site visit and found the septic system to
ier. No sanitary nuisance or public health
an existing garage. The Department has no
reported to this office and confirmed, you
bring the septic system into current code
FORMANCE OF THE SEPTIC SYSTEM
G THIRTY (30) DAYS FROM THIS
u may contact me at 462-3939.
Enviromental Health'• Storage Tank
714 Avenue C • P.O. Box 580 • ort Pierce, Florida 34954
(561) 462-3939 • SC 259-393 • Fax (561) 462-3948
F
o �Q STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
a?e APPLICATION FOR CONSTRUCTION P
Authority: Chapter 381, FS &
APPLICATION FOR:
[ ] New System [ J Existing System [ ]
[ ] Repair ( ] Abandonment [ ]
APPLICANT: We-
e- 1Q C� H 1_
AGENT: it f����� r���_�,�y�6,.�2�r�_
MAILING ADDRESS:��O
-------------------------------------
TO BE COMPLETED BY APPLICANT OR APPLICANT'S A
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED
---------------------------------------------
PROPERTY INFORMATION [IF LOT IS NOT IN A RECO
LOT`V/ -271 BLOCK: SUBDIVISION:
PROPERTY ID. #ID. #: _t[[SS
PROPERTY:SIZE: ACRES [Sgft/43560]
Aft33S
PROPERTY STREET. ADDRESS:Lpf 4
DIRECTIONS TO PROPERTY: �.Jr,(.i-Qrd�l4e
t
• 9
SCANNED cx� l lyg
PERMIT #
tudP r inf, DATE PAID
FEE PAID $
KIT RECEIPT #
apter 1OD-6, FAC
ing Tank
r(Specify)
[ ] Temporary/Experimental
TELEPHONE:logg _1387
"•
RIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
-----------------------------------------------
:DED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
DATE OF
SUBDIVISION:
fiction/Township/Range/Parcel No.-] ZONING:
ROPERTY WATER SUPPLY: [ '] PRIVATE [ ] PUBLIC
n 1 17L_ �Llsx?n
.BUILDING INFORMATION [ ] RESIDENTIAL
;Xnit Type of a No. of B i.
No Establishment Bedrooms A,e;
3 r
4
r)
,'[ ] COMMERCIAL
# Persons Business Activity
a Served For Commercial Only
[ ] Garbage Grinders/Disposals [ ] Spas/Hot Tubs
[ ] Ultra -low Volume Flush Toilets [ ] other (Specify)
APPL I CANT ' S SIGNATURE: �Xn 2a/Wy� /
-�
[ ] Floor/Equipment Drains
DATE: /
DH 4015, 10/96 (Replaces HRS-H Form 4015 [Page 1] which may be used) - Page I of 3
(Stock Number: 5744-001-4015-1)