HomeMy WebLinkAboutD O H APPLICATION FOR PERMITSTATE OF FLORIDA PERMIT NO. SL6 3 !W
DEPARTMENT OF EEALTR DATE PAID s
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
#� SYSTEM RECEIPT #: r
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION' FORS
[-✓ 1 New System { 1 Eciati.ng System [ J Holding Tank [ J Innovative
[ 1 Repair [ .] Abandonment [ 1 Temporary [ J�ale6�
APPLICANT: L/Y1 COn S �`/f� c 'i011 4�9f.-. 00,
AGENT. TELEPHONE
MAILING ADDRESS: /5--6 V -y 6
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TO BE COMPLETED BY'A•PPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A!PHRSON 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) IP REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
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PROPERTY INFORMATION
LOT:i BLOCK: SUBDIVISION:
PROPERTY ID #: 80 9— (1,72,-M9,36-bm e
PLATTED:
ZONING: I/M OR BOUIVALENT: [ Y/( 1
PROPERTY SIZE: ACRES WATER SUPPLY: IX] PRIVATE PUBLIC [ 1<-2000GFD ( J>2000GPD
IS SEWER. AVAILABLE AS PER 381.0065, Fs7 ( Y I� .) DISTANCE TO SEWER: /'-//4- FT
PROPERTY AbDitBSSslafa' 1 L Y7 /rf/'�•< �, ��-
DIRECTIONS TO PROPERTY:
�NC/S77 O /7
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BUILDING INFORMATION [] RESIDENTIAL [ J COMMERCIAL
wit! Type of No. of Building Commercial/Institutional System Design
No Butablishmwent Bedrooms. Area Sgft Table 1, Chapter 64E-6, PAC
1 /G l�?rn r r Res. j
I
2
3
4 1
[ l 83oor/ScNtipment Dz'aina
[ J Other (specify)
SIGiNATURS:
DR +4015, 08/09 (Obsoletes. previous editions which may not be used)
Incorporated 64E-6.001, PAC -
DATE:
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