HomeMy WebLinkAboutSEWAGE APPLICATION FOR CONSTRUCTION & APPROVALr
SGAWNLU
BY
9n STATE OF FLORIDA S'�tllel��'r111P1�` PERMIT N0.
DEPARTMENT OF HEALTH DATE PAID: _
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
SYSTEM RECEIPT # :
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ ] New System [L>1' Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment [ ] Temporary [ r/ ] Plan Review
APPLICANT;
AGENT: i d'a O lyyL' t'SGJ ` �'Pz�S�"rUC i-(�r� Yw t TELEPHONE: T72- 2L'L -77 j
MAILING ADDRESS: (r"6 l �Wt+f S^f►� Ga I e i 1 �+ t`L FL 3 Lf 1 1C
_ _ _ '__ cecec=ccecacc==c=cc=c�•cc==a=a==a=cc=ec=�aacc=acc=a=caccccccacc=cc
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: BLOCK:- SUBDIVISION: Qu�e-j,1 e'✓e PLATTED:
PROPERTY ID # : 1904 -lei) 00 94 0 00:2 ZONING: I /M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE:
ACRES WATER SUPPLY: [-- ]
PRIVATE
PUBLIC [4,1�3-<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS
PER FS? [ Y/N
DISTANCE TO SEWER: FT
PROPERTY ADDRESS:
I]
//381.0065,
`I
P j``�cdz.2tilt ��
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
[ ] Floor/Equipment Drains
SIGNATURE:
[ ] RESIDENTIAL I [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sgft Table t, Chapter 64E-6pp, PAC
�
116
I
[ ] Other (Specify)
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
DATE:
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