HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - 1-7-98STATE- OF FLORIDA
PERMIT ,# �/ d
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DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID"
ONSITE'SEWAGE DISPOSAL SYSTEM
FEE PAID
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APPLICATION FOR CONSTRUCTION PERMIT
RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
SGANN
D
BY
APPLICATION
FOR:
St Lucie P
unty
[x ] New System
[ ] Existing System [ J Holding Tank
[ ] Temporary/Experiments
[ ] Repair
[ ] Abandonment [ ] Other(Specify)
APPLICANT:
ROSERT & CYi�THIA JOLLY
TELEPHONE:
461m1963
AGENT:
PORT ST. LUCIE PROPERTIES/AYLOR, INC.
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MAILING ADDRESS:
4001 Ave. D.. Ft. Pierce, Florida 34947
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TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT.
ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6,
FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION,
ATTACH LEGAL DESCRIPTION OR
DEED]
LOT: BLOCK: SUBDIVISION: DATE OF
6 6 Jay Gardens 1-10-57
SUBDIVISION: -
PiYOPERTY ID #4 [Section/Township/Range/Parcel No.] ZONING:
PROPERTY STZE. ACRES•` Sgft/43560] PROPERTY WATER SUPPLY: [X ] PRIVATE [ ] PUBLIC
1! 14.675 `
PROPERTY STREET ADDRESS:
!� 8 VJ. Ave. 8. FtA RM Pierce. Florida
DIRECTIONS TO PROPERTY:
j See attached site man
it
BUILDING INFORMATION [X ]
RESIDENTIAL [
]' COMMERCIAL
Unit
Type of
No. of Building
# Persons
Business Activity
No
Establishment'
Bedrooms Area Saft
Served
For Commercial Only
t
1
'
1 Story residence
3 1293
4
2
3
4
I
41
-
A
[1 ]
GarbagelGrinders/Disposals
[0] Spas/Hot
Tubs
[0 ] Floor/Equipment Drains
[0 ]
Ultra -low Volume Flush Toilets
[ 0 ] Other (Specify)
i
c
,
�
APPLI
CANT ' S SIGNATURE : Q
(}
DATE: 1-7 ®gg
t
HRS-H
Form 4015, Mar 92 (Obsoletes previous
editions which may not be used)
Page 1 of 3
(Stock Number: 5744-001-4015-1)
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE;._
AGENT:
_a JI3:
MAILING ADDRESS:
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION
PROPERTY IDN:
PROPERTY SIZE:
WATER SUPPLY
PROPERTY ADDRESS
DIRECTIONS:
Check type of permit, if "Other" specify type in blank.
Property owner's full name.
Telephone number for applicant or agent.
Property owner's legally authorized representative.
P.O. box or street, city, state and zip code mailing address for applicant or agent.
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision
legal description or deed must be attached.
Official date of subdivision recorded in county plat books (month/day/year) or date lot originally recorded. Dig
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot
27 character number for property. (CPHU may require property appraiser ID M or section/township/range/pare
Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, n
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsu
may be included in calculating lot area.
Check private or public.
Street address for property. For lots without an assigned street address, indicate street or road and locale in
Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table H, Chapter 1013-6, FAC. Examples: single family, single wide mobile
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping acco
occupants.
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding, garage, carport, exterior storage
screened patios or decks. Based on outside measurements for each story of structure.
# PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other
Table II, Chapter 1013-6, FAC.
i copy of the lot
ling an approved
number.
nd prepared road
rahes, or other
ace obstructions
ty.
no, restaurant,
lations for
or open or fully
room are
a required by
FDCTURES: Mark each listed fixture with number installed or "NA" if not applicable. I i
SIGNATURE: Signature of applicant or agent. Date application one day submitted to the CPHU with appropriate fees and at Ihments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimman ((pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed Wells, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, s rface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. I ation of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For no sidential
establishments, afloor plan showing the square footage of the establishment, all plumbing drains and fixture tys, and other
features necessary to determine composition and quantity of wastewater. 111