HomeMy WebLinkAboutD O H SEWAGE TREATMENT DISPOSAL SYSTEM CONSTRUCTION PERMITSTATE OF FLORIDA PERMIT NO S
DEPTMENT OF HEALTH SV:
~ - ONSITE SEWAGE TREATMENT AND DISPOSAL �� y ENNE
EPAID: Gap
SYSTEM •'��Ge County
#: CK.i ll
APPLICATION FOR CONSTRUCTION PERMIT tY
APPLICATION FOR:
IVI New System [ I Existing System [. ] Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment [ ] Temporary [ ]
APPLICANT: a effne C> -S ari k- 1dV
AGENT; (�, I p6r;, Q C. co "41 • a A
p
TELEPHONE : � s/ 1 `4ft d7- 6'117
MAILING aa�DRESS: ift< Ayelmt f (&"a .'Ps(. 3 q g (y
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
APPLICANTS 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: �Ake W 010CI Petrk UAd+ b PLATTED:
PROPERTY ID #: 1 30 l —100 (o - 004?11v ®C0
—_AONING: )LS I/M OR EQUIVALENT:
[ YIN ]
PROPERTY SIZE: ACRES WATER SUPPLY: [Vf PRIVATE
PUBLIC [ ]<=2000GPD [
'1>2000GPD
IS SEWER AVAILABLE AS PEER 3/81.0065, FS?
[ Y/® ]
DISTANCE -TO SEWER:
T5 0 FT
00
PROPERTY ADDRESS: /C-) ( D
L��/v
(%(, '(�/•�
�"
DIRECTIONS TO PROPERTY, f ti I C,
1� �' Q W =A
je6, k�e 71�� �
e
40 PP
ONA
1 P-C-4- (S O'Jt -Aide 1
BUILDING INFORMATION
I
Unit Type of
No Establishment
1 -Srr�
2
i
3
a_
[ I Floor/Equipment Drains
SIGNATURE: I A�
[ RESIDENTIAL [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sgft Table 1, Chapter 64E-.6, PAC
3 / .515-
[ I Other (Specify)
DATE: z?/
DR 4015, 08/09 (Obsoletes previMis editions which may not be used)
rncorporatedl04E-6.001, PAC
Page 1 of 4