HomeMy WebLinkAboutD O H SEWAGE DISPOSAL - CONSTRUCTION PERMIT - 10-7-97STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
- 5 ONSITE SEWAGE DISPOSAL SYSTEM
-� APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS,& Chapter 10D-6, FAC
CCU lVE �
APPLICATION FOR:
[X'] New System [ ] Existing System [ ] Holding Tank
[ ] Repair'i [ ] Abandonment [ ] Other(Specify)
APPLICANT: ROGER A SANDRA SHINN
AGENT': PC T ST. LUCIE PROPERTIES/AYLOR, INC.
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MAILING ADDRESS:
115 U. Vista Ct., Ft. Pierce, Florida 34947
PERMIT #
DATE PAID
FEE PAID
RECEIPT # A
e
[ ] Temporary/Experimental
TELEPHONE: 5AGANNEL)
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6
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 INFIORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: �j BLOCK: SUBDIVISION: DATE OF
1 109 Lakewood Park Unit 9 11-19®58
SUBDIVISION•
PROPERTY ID I: [Section/Township/Range/Parcel No.] ZONING:
.PROPERTY SIZE:14,170 ACRES [Sqf �43560] PROPERTY WATER SUPPLY: [ X] PRIVATE [ ] PUBLIC
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PROPERTY STREET ADDRESS:
!' Penny La.. Ft. Pierce, Florida
DIRECTIONS TO PROPERTY:
See attached site mao
BUILDING INF",ORMATION
[X ] RESIDENTIAL [
] COMMERCIAL
Unit
Type of
No. of Building
# Persons
No
Establishment
Bedrooms Area Saft
Served
1
1 Story;lresidence
3 1753
4
2
3
I�
4
[ 1 ] Garbage.' Gii'inders/Disposals [0 ] . Spas/Hot Tubs
[0 ] Ultra -low Volume Flush Toilets L0 ] Other (Specify)
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APPLICANT'S SI
c
HRS-H Form 4015,,jMar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4015-1)
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Business Activity
For Commercial Only
10 ] Floor/Equipment Drains
DATE: 10-7®o7
Page 1 of 3
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
cliff
Check type of perinit, if "Other' speQify type in blank.
Property owner's fill! 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, Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in recorded subdivision, li'copy of the lot
SUBDIVISION: i., legal description or deed must be attached.
DATE OF,S�QDkyl 1014-t Wficial date of subdivision recorded in county plat books (month/day/year) or date loi originally recorded. Divi ing 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 # orsection/township/range/parce �number.
PROPERTY SHE: Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road
beds within public rights -of way or casements and exclusive of streams, lakes, normally wet drainage ditches, 12-41.1res, or other
III
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsur cc obstructions
may he included in calculating lot area. III
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county,
DIRECTIONS: Provide dctaitcd instructions to lot or awwh an area snap showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table 11, Chapter 1013-6, FAC. Examples. single family, single wide mobile h6me, restaurant,
doctor's off", Ali
NO. BEDROOMS: COUtIt all 1`001Tis designed primarily for sleeping and those areas expected to routinely provide sleeping accomm i d�atlomi for
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 desks. Based on outside measurements for each story of structure.
II
# PERSONS:
Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per b(l.
room are
assumed,
BUSINESS ACTIVITY:
For commercial applications only. List number of employees, shills, and hours of operation, or other informati,"n
required by
Table 11, Chapter 1013-6, FAC.
FIXTURES:
Mark each listed fixture with number installed or "NA' if not applicable.
I.
Date day to the CPHU fees
SIGNATURE:
Signature of appfiearit or agent, application one submitted with appropriate and attachments.
A17ACHMENTS:
A site plan drawn to scale, showing boundaries with dinterI locations of residences or buildings, swimming
I. foolls, recorded
ersenicars, onsite sewage disposal systogo components and location, slope of property, any existing or proposed
elI8. dr4ia-aige
features, filled Press, 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. I
ciation of any
public well within 200 feet of lot.
lip
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments,ii floor plan showing the square footagr of The establishment, all plumbing drains and fixture I'
`
�s and other
necessary necesry to determine composition and quantity of wastewater. I
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