HomeMy WebLinkAboutHEALTH DEPARTMENT ONSITE SEWAGE TREATMENT APPLICATION FOR PERMITSCANNED
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STATE OF FLORIDA 9 Lucie county
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
PERMIT NO.
DATE PAID:
FEE PAID: OJO C. 01
RECEIPT #:
PPLICATION FOR: Holding Tank [ ] Innovative
r/] New System [ ] Existing System [ ] g
] Repair [ ] Abandonment \ [ ] Temporary [ ]
PPLICANT: �RTY /3US7�%l� %��707�•� TELEPHONE:'%�' �Z
J�3r7i % 7
GENT: ��] /y� p Q
AILING ADDRESS: 7gd2 S<< Aygp ",t%B R r/,�1�04Q
0 BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ^SYSTEMS MUST ^SE CONSTRUCTED
Y A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES,
IT IS THE
PLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
LATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
IiRopERTY INFORMATION _----_
IOT:� BLOCK: SUBDIVISION:994z Mig"' � / kfff PLATTED:
R
ID #: 3�ar�so��yaI ZONING: I/M OR EQUIVALENT: [ Y/N I
PERTY SIZE: !i%� ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [ ]<=2000GPD [ >2000GPD
DISTANCE TO SEWER: lar * FT
SEWER AVAILABLE AS PER 3 81. 0 0 6 5 ,` QFS J.f � [ Y /I N I ] p ? ) , J��j /
PERTY ADDRESS: / 7� Jk)b1i 860i� ll19? V r Poo dr/ 1 Vvt &' 7I a b r
.ECTIONS TO PROPERTY:
ex Mil I
UILDING INFORMATION [ ] RESIDENTIAL [ ] COMMERCIAL
snit Type of No. of Building Commercial/Institutional System Design
fo Establishment Bedrooms,_ Area Sqft Table 1, Chapter 64E-61 FAC
-7/ S�2
2
3
4
] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE: C% "/ DATE:
)1H 4015, b8/09 (Obsoletes previous editions which may not be used) page 1 of 4
Cnco=orated 64E-6.001, FAC