HomeMy WebLinkAboutD O H ONSITE SEWAGE TREATMENT DISPOSAL - APPLICATION FOR PERMITit
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STATE OF MORIDA PERMIT NO.
. . . . . . . ... DEPARTNlSNT QV RgALTH DATE PAID -
014SM .SEWAGE TREATMENT AND DISPOSAL FEE PAID:
RECEIPT
W1.
AFPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
New System Existing System Holding Tank 1, 1 innovative
Repair Abandonment Temporary 1X11 Pon 6(wew
APPLICANTO
AGENT: TELEPHONE:
MAILING -ADDRESS: 4144que- Ac- f < el, ays?i
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TO BE'COMPLETED BY APPLICANT 09 APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON ON LICENSED PURSUANT TO 48.9.105(3),.(m) OR 489.559, FLORIDA STATPTE-$. IT IS THE
APPLI&AkR" . S RESPONSIBILITY . . TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR SCANNEDD
PLATTED (&M/Db/YY,) IF R20PESTING CONSIDERATION -OF STATUTORY GRANDFATHER PROVISIONS. BY
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PROPERTY INFORMATION
SUEJDIVISION: LOT: BLOCK: PLATTED:,
D PROPERTY ID #: A10,5 701-0070'0()0-'Z ZONING: XS i/M, OR EQUIVALENT: E. Y / (,&
' I /
PROPERTY SIZE-: ACRES WATER. SUPPLY: f- j PRIVATE PUBLIC. .[• ]<#2*000GPb-
%--,>
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y I...N DISTANCE TO SEWER: FT
I -
PROPERTY ADDRESS: Am 61t,0,P k 3 LO
TO PROPERTY.,.:
BUILDING INFORMATION I L/RESIDENTIAL COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
E ;A61ighmo#t Bedrooms Area
,,a $qft Table. !�, CApter FAC
7
Ala 139d600m 1
3 I
4
Floor/E men.t Prains Other
(.Specify)
q1SIGNATURE, - DATE:
)9 4015, 0.8 1 Q9 (Obsolletes previous editions which may not be used)
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