HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - 5-13-97APPLICATION
IX ] New Sy
[ ] Repair
APPLICANT:
AGENT:
STATE OF FLORIDA PERMIT # +
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID y�
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ZV
APPLICATION FOR CONSTRUCTION'PERMI__ RECEIPT # l^
Authority: Chapter 381, FS & Chapter 1OD-6, FAC ,
'OR �4
:em [ ] Existing System ( ] Holding Tank
[ ] Abandonment [ ] Other(Specify)
MICHAEL JOHNSON,ITRACY DIGEORGIO
RT ST, LUCIE PROPERTIES/AYLOR, INC.
I'
MAILING ADDRESS:1. 9801 S. Ocean Dr. #435, Jensen Beach, Florida 34957
[ ] Temporary/Experimental
TELEPHONE: _ ____
!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.
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PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: 33&34 BLOCK: 20 SUBDIVISION: Indian River Estates #6 DATE OF Aug. 7, 1956
SUBDIVISION:
PROPERTY ID'#: [Section/Township/Range/Parcel No.] ZONING:
PROPERTY SIZE*9®600 ACRES ft 3560] PROPERTY WATER SUPPLY:' [ X ]' PRIVATE [ ] PUBLIC
PROPERTY STREET ADDRESS: Silver Oaks Drive, Ft. Pierce, .Florida
j
DIRECTIONS TO PROPERTY: See attached site map
BUILDING IN ORMATION
Unit Type of
No Establishment
- I
1 1 Stork resddence
2
i
3
4
[X ] RESIDENTIAL [ ] COMMERCIAL
No.. of Building # Persons Business Activity
Bedrooms Area Soft Served For Commercial Only
Garbago Grinders/Disposals [0 ] Spas/Hot Tubs [0 ] Floor/Equipment Drains
[ 0] Ultra -low Volume Flush Toilets [0 ] Other (Specify)
APPLICANT'S SIGNATURE: DATE:
HRS-N Form 4015 Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4015-1)
s -•
5-13-97
Page 1 of 3
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION:
PROPERTY #
PROPERTY SIZE:
WATER SUPPLY:
PROPERTY ADDRESS:
Cherk type of pcan;t, if "Other' specify type in blank.
Property owner's "I 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 recordcdsubdivision,:!a copy of the lot
legal description or deed must be attached.
ii
Official date of subdivision recorded in county plat books (mornh!day/year) or date lot originally recorded. DM2'ing an approved
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 # or section/township/range/parcei I number.
.id prepared road
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 casements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and casements with no substI obstructions
may be included in calculating lot area.
Check privale or public.
Street address for property. ror lots without an assigned street address, indicate street or road and locale in county. l
DIRECFIONS: Provide detailed instructions to lot or attach all area [nap allowing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENIT: List type of establishment from Table 11, Chapter IOD-6, FAC. Examples: single family, single wide mobile ho no, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for steeping and those areas expected to routinely provide sleeping accommoial ions for
occupants. II
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed,�jor open Of 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 bedroom are
assumed. i
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other informatlinj required by
Table 11, Chapter IOD-6, PAC.
FiXTURES: Mark each listed fixture with number installed or 'NA' if not applicable.
SIGNATURE: Signature of applicant or agent. Date application one day submitted to the CPHU with appropriate fees and attacl 1—nts.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, ak)pe of propertyany existing; or proposed w" I ells. drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surfac-, Waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. L(XaItion of any
public well within 204) feet of lot.
. i
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
I establishments, a floor plan showing the square footage of the establishment, all plumbing drains scat fixture typesl and other
features necessary to deter -mine composition and quantity of wastewater.