HomeMy WebLinkAboutSEWAGE APPLICATION FOR CONSTRUCTIONi
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�17te �l���U�"l�akJJ
r STATE OF FLORIDA
. DEPARTMENT OF HEALTH ���UCIeCeUil�
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
y�°'°'`�• APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] New System [ -ul' Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair, [ ] Abandonment [ ] Temporary [ t( ] Plan Review
APPLICANT,.
AGENT:
MAILING ADDRESS:
TELEPHONE: Z.%)d Jy' �I
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUHOR TIZED 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:BLOCK: SUBDIVISION: SG/nao^,-? PLATTED:
PROPERTY ID # : /_ �� _ r �✓ `y® � � � 30NING : I /M OR EQUIVALENT: [
PROPERTY SIZE: .,?k ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC Vj<=2000GPD [ 2>2000GPD
IS SEWER AVAILABLE AS PER 3811.0065, FS? [/6� N ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: IZ3041 Al..
DIRECTIONS TO PROPERTY: &4 Gig G?:I �`�•h7i /.-CW 'go
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
2
3
4
[ ] Floor/Equent Drains [ ] Other (Specify)
SIGNATURE:
DH 4015, 08/079 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
DATE:
J
Page 1 of 4
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0
(60)
FDOH in St. Lucie County
Environmental Health
Septic System Appears Adequate
For Proposed Construction SG517-0%466
This Approval Does Not Guarantee
Performance of the System
Reviewer:
N
httn://www.nasle.org/ImaLeSketches/sketch/18/18988 20646 UDia 6/7/2018