HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - 2-24-97STATE OF'•-FLORIDA PERMIT #
DEPARTMENT OF HE AND REHABILITATIVE SERVICES DATE PAID
. FEE PAID $
ONSITE SEWAGE D`��AL SYSTEM
-mod APPLICATION FOR CONSTRUCTION PERMIT RECEIPT #
Authority: Chapti, FS & Chapter 10D-6, FAC
APPLICATIONI'FOR:
[X ] New System
[ ] Repair
APPLICANT:(
ROEM
AGENT:
P0! ZT SY
MAILING ADD SS:
[ ] Existing System
[ ] Abandonment
[ ] Holding Tank [ ] Temporary/E
( ] Other(Specify)
TELEPHONE:
770-
TO BE COMPL TED BY APPLICANT•OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN S OWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY IN;ORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: SUBDIVISION: DATE OF
2$ 20 Lakewood Park #3 SUBDIVISION: 9®
PROPERTY ID I#: [Section/Township/Range/Parcel No.] ZONING:
I'I
PROPERTY SIZ :! ACRES [Sgft 43560] PROPERTY WATER SUPPLY: [X ] PRIVATE [ ] PUBLIC
13920
PROPERTY ST ET ADDRESS:
j ' Palomar St .Ft Pierce Florida
DIRECTIONS_ TO PROPERTY:
1 [ See attached site map
I
1
i
BUILDING INFORMATION
[X ] RESIDENTIAL
[
] COMMERCIAL
Unit Type of
No. of
Building
# Persons Business Activity
No Establishment
Bedrooms
Area Soft
Served For Commercial Only
1
i
�
1 Sto
esidence
3
1473
2
i
t
I
3.,
4
[ 1 ] Garbage
[ 01 Ultra-1
APPLICANT'S
rinders/Disposals [0 ] Spas/Hot Tubs
Volume Flush Toilets [0 ] Other (Specify)
[0 ] - Floor/Equipment Drains
DATE: 2-24-97
HRS-H Form 4015, Mar 92 (obsoletes previous editions which may not be Used) Page 1 of 3
(Stock Number: 5744-001-4015-1)
APPLICATION FOR;
Check type of perinit, if "Other' specify type in blank.
APPLICANT:
Property owner's full na-me.
TELEPHONE:
Telephone number for applicant or agent.
AGENT:
Property owner's legally authorized representative.
MAILING ADDRESS:
P.O. box or street, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK'—.
Lot, block, and subdivision for lot (rerorolcol or unrecorded subdivision). If lot is not in a recorded subdivision, a'copy of the lot
SUBDIVISION:,
legal description or deed must be attached.
DATE OF $UBDIVISJON:
Official date of subdivision recorded in county plat bcKiks (inonth/day(year) or date lot originally recorded. -Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
PROPERTY ID#:
27 character number for property. (CPHU may require property appraiser ID # orwctionitownship/range/iiisrce), Inumber.
PROPERTY SIZE:
Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas a ' 6d prepared road
beds within public rights -of way or casements and exclusive of streams, takes, normally wet drainage ditches, rujrshcs, or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
WATER SUPPLY:
Check private or public.
PROPERTY ADDRESSF,
Street address for property. For lots without an assigned street address, indicate street or road and locale in couift
ly
DIRECTIONS:
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 11, Chapter IOD-6, FAC. Examples: single family, single wide mobile hd ; me, restaurant,
doctor's office,
NO. BEDROOMS:
Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommdalions for
occupants.
II
BUILDING AREA:
Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed,, or open or fully
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 be room are
assumed. I
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other informati jn required by
Table 11, Chapter IOD-6, FAC.
FIXTURES: Mark each listed fixture with number installed or 'NA' if not applicable.
SIGNATURE: Signature of applicant oriipeuE. Date application one day submitted to the CPHU with appropriate fees and auz!lifnents.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of resiolcmes or buiidings, swiinmin� ��
pools, recorded
easements, onsite sewage disposal sysiern components and location, slope of property, any existing or pro>poseJ'wells, drainage
feature,,;, filled areas, obstructed areas, and surfacc, water. Locafii)n of wells, onsite sewage disposal syawns, a i rfac-, waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. lx,�11 'catlon of any
public well" within 200 feet of lot. 11
For residences, a floor plan (reskicivc5),showing number of bedrooms and building area,of each unit. For non sidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture tyi es, and other
features necessary to determine composition and quantity of wastewater. 1.