HomeMy WebLinkAboutD O H PAPERWORKSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND
SYSTEM
RE�FIVFD
DISPOSALNnV 2018
Pe rt7ktin9 D pd
tuCle County ent
PERMIT #:56-SF-1888100
APPLICATION #:AP1370892
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1181210
CONSTRUCTION PERMIT FOR: OSTDS New SCANNED
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APPLICANT: Glenn Muse
PROPERTY 1 ADDRESS : 5821 Mustang Cir Port Saint Lucie, FL 34987
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LOT: 38 BLOCK:
SUBDIVISION: Pony Pines
PROPERTYID#: 3309-605-0041-000-3 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
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SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065,i F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS,
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE IOF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR1LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
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T [ 1,050 ] GALLONS / GPD _ Septic new CAPACITY
A [ ] GALLONS % GPD N/A CAPACITY
N [ I ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ I ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24-HRS #Pumps [ ]
D [ 5001 ] SQUARE FEET Drainfield new SYSTEM
R [ I] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [X] MOUND [ ]
I CONFIGURATION: [X] TRENCH [ ] BED [ ]
N I
F LOCATION IOF BENCHMARK: Site BM o
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
e paint diamond CL of mustang circle center of
11.00 1 [1 INCHES k FT ][ABOVE A BELOW BENCHMARK/REFERENCE POINT
11.00 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
D'FILL REQUIRED: [18.001 INCHES EXCAVATION REQUIRED: [ ] INCHES
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
0 400 gpd.
T The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with
H s. 64E-6.0 3(3)(f), FAC.
E
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SPECIFICATIONS BY: Brian J In ram TITLE: Environmental Specialist II
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APPROVED BY:I TITLE: Environmental Specialist II St. Lucie CHD
DATE ISSUED:
Brian J In am
11/16,2018
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
EXPIRATION DATE: 05/16/2020
Page 1 of 3
v 1.1.4 IC
FE C
t 7R1�
NOTICE OF RIGHTS
i A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one (21) days from the receipt of this order. The address of the
Agenncy Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency
Clerk's facsimile number is 850-413-8743.
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Mediation is not available as an alternative remedy.
i Your failure to submit a petition for hearing within 21 days from receipt of this order will
constitute a waiver of your right to an administrative hearing, and this order shall become a 'final
order'.
l Should this order become a final order, a party who is adversely affected by it is entitled
to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are
governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced
by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a
second copy, accompanied by the filing fees required by law, with the Court of Appeal in the
appropriate District Court. The notice must be filed within 30 days of rendition of the final order.
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St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
HEALTH
PAYING ON: PERMIT#: 56-SF-1888100 BILL DOC #:56-BID-4006434 CONSTRUCTION APPLICATION #: AP1370892
RECEIVED FROM: Glenn Muse AMOUNT PAID: $ 515.00
PAYMENT FORM: CHECK 2046 PAYMENT DATE: 10/29/2018
1
MAIL TO: ' Glenn Muse
FACILITY NAME:
PROPERTY LOCATION:
58211 Mustang Cir
PortSaint Lucie, FL 34987
Lot: 38
Property ID:
3309-605-0041-000-3 '-
EXPLANATION or DESCRIPTION:
Block:
128 - OSTDS Construction System Inspection Research Fee
-1 - Surcharge (All)
-1 - OSTDS New Permit Surcharge
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-1 - OSTDS, Construction Application and Plan Review,New
123 - OSTDS Construction Site Evaluation
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126 - OSTDS Construction Permit (New or Mod, Amendment)
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127 - OSTDS Construction System Inspection
133 - OSTDS Construction Reinspection
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QUANTITY
1
1
1
1
1
1
1
1
FEE
$ 5.00
$ 15.00
$ 100.00
$ 100.00
$ 115.00
$ 55.00
$ 75.00
$ 50.00
RECEIVED BY: MontanezNM AUDIT CONTROL NO. 56-PID-3781622
DIRECTIONS1TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
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2
3
4
[ ] Floor/Equipment Drains
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SIGNATURE:
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STATE OF FLORIDA
b ) '' � I DEPARTMENT. of HEALTH
Z' ONSITE SEWAGE. TREATMENT AND DISPOSAL
�.� SYSTEM
'•''G""�e APPLICATION FOR CONSTRUCTION PERMIT
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APPLICATION FOR:•
[ ,xI New S stern
PERMIT NO.
s,F 18 ®V.
DATE PAID:
�j
E
FE PAID:
RECEIPT It:
ZOS0A'
y C ] Existing System [ ] Holding Tank [. ] Innovative
C ] Replair C ] Abandonment C ] Temporary [ ]
APPLICANTI: C� I -en 11 M u5--p
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AGENT:
MAILING ADDRESS: v YU X D. (11 06
=_-- --I — Ur4- �� idCr
TELEPHONE : 7� - y l� - 363 7
TO BE -COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON 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 (*/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY IIFORMATION ------ -- ---- —_
LOT: 0_ BLOCK: SUBDIVISION: () (,S U I PLATTED:
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PROPERTY ID It: ZONING: I/M OR EQUIVALENT: [ Y
PROPERTY.SIIZE: , ACRES WATER SUPPLY: [/�] PRIVATE PUBLIC [ ]<=2000GPD [ 1?2000GPD
E IS SE.WR AVEAILABLAS PER 381.0065, FS? [ Y '/ I0] DISTANCE TO SEWER: ' FT
PROPERTY ADDRESS : 8�� (j� n j� el
UI
EX] RESIDENTIAL,
tv
[ ] COMMERCI L
E
No. of ' Building Commercial/ -Institutional System Design
Bedrooms Area SSf-t Table 1, Chapter 64E-6, FAC
[ ] Other (Specify)
AS �)
DATE: IfJai l l p"
DU 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorpora ed 64E-6.001, FAC
�1a .�
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Page 1 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATION
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APPLICANT: Glenn Muse
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CONTRACTOR / AGENT: Glenn Muse
LOT: 38 BLOCK:
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SUBDIVISION: Pony Pines ID#: 3309-605-0041-000-3
APPLICATION # AP1370892
PERMIT # 56-SF-1888100
DOCUMENT # SE1131135
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDE
REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
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PROPERTY SIZE CONFORMS TO SITE PLAN: ( [X]YES [ ]NO NET USABLE.AREA AVAILABLE: 1.86 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ]
AUTHORIZEDi SEWAGE FLOW: 2790.01 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 1200.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1200.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Site BM orange paint diamond CL of mustang circle center of property
ELEVATIONIOF PROPOSED SYSTEM SITE 11.00 [ INCHES / FT ] '[ ABOVE / BELOW ] BENCHMARK/REFERENCE POINT
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THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: FT DITCHES/SWALES: FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: 85 FT NON -POTABLE: FT
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BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 87 FT POTABLE WATER LINES: 70 FT
SITE SUBJECT TO FREQUENT FLOODING? [ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO]
10 YEAR FLOOD ELEVATION FOR SITE: FT[ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD
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SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
USDA SOIL SIERIES:Nettles sand
Munsell #/Color Texture
Depth
10YR 5/1
Sand
0 To 15
1 OYR 6/2 1
Sand
15 To 31
1 OYR 7/2 I
Sand
24 To 36
1 OYR 4/2
Sand
36 To 41
1 OYR 3/1
Sand
41 To 57
1 OYR 5/3
Loamy Sand
43 To 57
1 OYR 2/1 i
Sand
57 To 61
1 OYR 4/4
Sand
61 To 72
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USDA SOIL SERIES:Nettles sand
Munsell #/Color Texture
Depth
1 OYR 5/1-
Sand
0 To 13
10YR 6/1
Sand
13 To 27
10YR 7/2
Sand
27 To 37
10YR 4/2
Sand
37 To 44
10YR 3/1
Sand
44 To 52
10YR 5/2
Loamy Sand
46 To 60
1 OYR 3/2
Sand
60 To 65
10YR 4/4
Sand
65 To 72
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OBSERVED WATER TABLE: 55.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: [ PERCHED / APPARENT ]
[ ABOVE / BELOW ] EXISTING GRADE
[X]YES [ ]NO
SITE EVALUATED BY: /
Ingram, Brian (Title:
DH 4015, 08/09 (Obsoletes previous editions which
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DEPTH: 27.00 INCHES
DEPTH OF EXCAVATION: INCHES
(SPECIFY)
ental Specialist II) (ENVIRONMENTAL HEALTH)
be used) Incorporated: 64E-6.001, FAC
AP1370892 EID1888100
DATE: 11 /02/2018
Page 3 of 4
v 1.0.2
ESTIMATED WE SEASON WATER TABLE ELEVATION: 24
INCHES
HIGH WATER TABLE VEGETATION: [ ]YES EX ]NO
MOTTLING:
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:
Sand/0.80
DRAINFIELD CONFIGURATION: [X ] TRENCH [ ] BED
( ] OTHER
REMARKS ADDITIONAL CRITERIA
WSWT determined using USDA WSS and soil borings.
10YR7/2 stripping in 10YR6/2 matrix >10% with diffuse boundaries starting at 24" in S61.
SB1 11" below BM. SB2 9" below Big.
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PPLICANT:
STATE OF FLORIDA
DEPARTMENT OF , HEALTH -
ONSITE SEWAGE TREATbMNT AND DISPOSAL, SYSTEM[
SITE EVALUATION AND SYSTEM SPECIFICATIONS
OT :
ROPERTx i ID I ]k :
PERMIT It.
AGENT:
f1rf /
BLOCK: SUBDIVISION: Ali e-5 0o Z ( 0,�
[ Sectio&TOWnshipfflarcc[ No. or Tax ID Number- ]
O BE COMPLETED By ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON- ENGINEERS
UST'PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
ROPERTX SIZE CONFORMS TO SITE PLAN: [ YES [ ] NO NET USABLE AREA AVAILABLE: r•'0 ACRES
0TAL ESTIMA E,D SEWAGE FLOW: �30 d GALLONS PER DAY [RESIDENCES -TABLE I/OTHER-TABLE2 ]
UTHORIZED. SEWAGE FLOW: GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
NOBSTRUCTED AREA AVAILABLE: ' `� f"` SQFT� UNOBSTRUCTED AREA REQUIRED: 6 <1 o SQFT
ENCHMARI{/REFERENCE POINT LOCATION;
LE NATION OF PROPOSED SYSTEM SITE IS [1WHES/FT ] [AB E/BELOW'] BENCHMARK/RE ;.RENCE POINT
BE, MINIMMI SETBACK WHICH CAN BE MATNTAINED FROM THE, PROPOSED SYSTEM -TO THE FOLLOWING FEATURES
URFACE WATER: An 4 FT DITCHES/SWALES: 7S FT • NO LX WET? [ I YES [N NO
ELLS: PUBLIC: O O FT LIMITED USE: •f?C% FT PRIVATE:�FT NON -POTABLE;: .5 3 FT
UILDING FOUNDATIONS: AD �` FT PROPERTY LINES: �'! FT POTABLE WATER LINES: . tFT
ITE.SUBJECT TO FREQUENT FLOODING: [ ] YES Ok NO 10 YEAR FLOODING? [ ] YES j] NO
0 YEAR FLOOD ELEVATION FOR SITE• FT MSL/NGVD SITE ELEVATION: FT MSL/I>TGVD
SOIL PROFILE
MUNSELL #/COLOR
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USDA SOIL!SERIES:
SITE 1
TEXTURE
DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
BSERVED WATER TABLE: INCHES [ABOVE/BELOW
STIMATED WE, SEASON WATER TABLE ELEVATION:
TGII; WATER TABLE VEGETATION: [ ] YES [X] NO
01.L-TEXTURE'/LOADING RATE FOR SYSTEM SIZING:
RAINI;IELD'CONFIGURATION: [ ] TRENCH [ ] BED
EMARKS/.ADDITIONAL CRITERIA:
SOIL PROFILE INFORMATION SITE 2
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO.
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
r] EXISTING GRADE- TYPE :[ PERCHED /APPARENT ]
_ INCHES [.ABOVE/BELOW ] ,EXISTING GRADE
MOTTLING. [ ] YES ) NO DEPTH: INCHES
.DEPTH OF EXCAVATION: INCHES
I ] OTHER (SPECIFY)
H 4015, 12/11 (Obsoletes previous editions which may not be used) incorporated: 64E-6.001, FAC Page 3 OL 4
STATE' OF FL0=A
]JAPART 6k RkAtTil
ONOM SEWAGE: TREATMENT :AND D±00SAt: SYSTEM
,CQNSTAUCTIPRINSPECTIQN, Z10 FIri1 L V M-OVAL
,G1enrtMuw____ . - --- ---
AGENT:
E y-� y3
PON" *,.68,sp-11888100
PATE :PAW-1 0/291201 8
#
AppgE$,s!-. 502.t Mustang Ur PqijSa1nt,.1uqie..,FL 34987
py
LOT-'-. 38,, AwdkSi Lucie County
V.1ix0a.:
CHECKED (X73* ITEMS: ARR NOS IIT COMPLIANCE' Wltil STATUTE dit'ROLE V0,JMUST BZCORRECTED,
TANK'
INSTALLATION
SETBACKS
EGX_11
TAtJK 'SIZE ru logmo, Eal,
E'
-1
r27j! AURFAdt !WtkR
E
'I. f02]"
TANX,MATEkIAL Co11C ete
E
'1
[281 DITCHES 58,
1
:1 t10.31:
OUTLET Pgyxizz"
Pi E Mlit .4.
f041
MULTI -CHAMBERED ELLY
x. j
C
1
[30.1 PUBLIC WSLLS FT
r057 damm vt,-LWER. P01Y1dk,pL.;68.
E I EPO-If LEGEND 1. MA'43-11bN z,
tf 'I
rb�7.1 I
WAT-131-RTIGHT-
[0811!
LEVEL-,
(691
Dtiltlf, TO tib
DFAINFIE10 IITST 10
1 j
[10c,'j[
AREA Cal 500
[.11]
IRRIGATION, WMtjc4
]tTl
I I
E,49]
PQTABLFi W
F7
C3,3]
BTj±fb.fk6' kO
et.
I 1
041
'PROPERTY LINES
Ys
OTHEP,
FILLW -,/ MOUND SYSTEM
4 E [341 DPjk1-Nr,_1-E= OVER
[
I till
PISTRIBUTION BOX HEADER
E
1
[37
SHOULDERS I
[
] 1121
NUMBER OF, -DRAINLINES 1..,4,00 2..
aLovk.!§
E.
'1 [131,
DRATMINE SEPARATION
1
[39.1
STABILIZATION:
E,.
['14]
DRAINL17M SLOPE
DEPTM OF'� COVER
ADDITIONAL 1NF6R1aTfOR:
�tj
[A.6,1 .
ELEVATION r, ABOVE
BELOW
"Did; zi 100
[0]
UNOBSTRUCTED AREA
[171
SYSTEM LOCATION
1
[411
!STOPMAATER RUNOFF`
f.
1 11#3
DOSING PUMPS
E"
'1 L119;j
A6Gi2E;GATF SIZE
C
j
r4,31
MAINTENANCE AGREEMENT
C20
AGGAk"TZ
1
E,,.4 '43
IL
BU 'DI$G, AREA.
t9f]
AGGREGATE_bE'PTH_
r,
1
101
L Qq?g;O� POP?ORMS WITH I IT.9 PLAN
rxzz.
ExcAvATioN MATERIAL
1
[,4 q 3
FINAL SITE GRADING
-LL, -- QUM
Z31 AM
. I
CONTA4CTOR. Ernest Dempsey,(;3t09tt-P1tf,
C
I E-Z-4ji
R-IL14-TEXTUR9.
[A 6-1
OTHER 'R kam6e
EXCAVATIOH.zwTg
ABANDONMENT
[25,,f
AREA REPLACED:
'E.491
TANK PUMPED
'REPLACEMENT MATERIAL
ESQI
TANK' CRUSHED" S FILLED
,qbp34qnts; Coukdrit6 -dke on page 2.
CoNsmwamxbw t. LUCID CHD� DATE::kw, 681016610,
DISAPPROVED . gyfign- LHEALTH)
ta gihi6 (PNV1RONMENTA
SYSTE DISAPPROVED ] EnQronmentAPS00CJa1%tjj,graLM:(ENY1RON.MELNucta cm 'DAt4z 1211112619
T4 HEALTH}
(Explanation ofViolaticnfi 66 Z611:6wifig, pag)6r
DH 401,0, 06/0,9. ftacilptwq, all:Prfavious�, it iled0 is#1,94 may ;19
.0
*'' I l. be used") : -
1nC6drA,te4,, 64k-6. OP3 . t FAG PAge2 of` 1.
EH Database, v1.00 tAFI.3.708SR EID1088100
P4 441i!G, 9V/O(05061otes: -aal -0�ov.14V# -dd:Lt!L-dns Y#h;Lch, may riot., bo U00ka), IMP Page :2. qf. I
9" Doolksw •044 AP1370892
, RCCEIVED
STATE OF FLORIDA PERMIT APPLICATION TO CONs7R151Cf, 21
REPAIR, MODIFY, OR ABANDON A WELL
� Permittln� ps
SC)1it1?WeSI 't"r_;=_E=1tLOUT ALL WlICAS1.6b
- Northwest i Denotes Required Fields Where A CA
StJohns River
yrouth Florida Nr
_SuwanneeRivei rsas:::1
DEP
G Delegated Authority ilf Applicable) _
N„
iJn;gveID
M
Simulations Rer kwa�d Sze Attached+ y"'
��
sad Nc Qe!meal.a� Nc. ��
UP Applicatir_.n No
I e=%terleN I yl Iu5e.. Y o. FSox 66vv n�f r0rc AAt--.,-e r-t. �N-ta-ts
Owner. Legal N me if Corporation cress "City State ZIP Telephone Number
5�z( al+ _ (_� Fi. 3�l
:rdeil Laration - 4ddress, Ro Name or Number City -
; oR- Coos- oo4i- O(3o--3
Parcel 1D No. (PIN) or Alteniale Key (Circle One) C Lot Block Unit
e, tilt s Li�2. Check if 62-5240 Yes Wo
Se Vion or Land Grant Township Range County Subdivision
s, Tim Huggins 11247 772-878-6698 absolutewaterservice@gmail.com
:;later Vfell Contractor License "!um ber Te!eonone Number E-mail Address
s. 268 SE Volkelts Terrace Port St. Lucie Florida 349883
(later t,Jeli Contractors Address City -� --- State ZIP
%• Type at'�Vork: Wonstrucbon ❑Repair ❑Modification❑ Abandonment
1 3. Number of Proposed '''dells i•:eas:: icr r?car M:afcgt,4n %AWrcortr;er.I
Ii Sperify Intended Use(s) of N/e (si. weStemp
Domestic 8 Landscape irrigation Agricultural irrigation 8 She Investigations
Bottled Water Supply Recreation Area Irrigation Livestock Monitoring
Public Water Supply (Limited Use/DOH) ❑ Nursery Irrigation Test
Public Water Supply (Community or Non-Communiry/DlP)� Commercial/Industrial Earth -Coupled Geothermal
Class I Injection Golf Course Irrigation HVAC Supply
HVAC Return
Class V Injection: ❑ Recharge ❑ Commercialllndustrial Disposal [] Aquifer Storage and Recovery ❑ Drainage
Remediation: ❑ Recovery ❑ AirSparge ❑ Other loesuibe)
t7if!tial Use C^fy
❑ Other ID-mb-)
0. Distance from Septic System ti 5 200 1' ,V.hty Des riptior. 12. Estimated Start Date
13 Estimated vlei! Depthk-L&R. Estimated Casino berth 't. PrimaryCasing Diameter �o. Open H,ile Frnm —To ft
to Esfirnated Screen Interval: From — To � k.
5. Primary Casing Material. Black Steel Galvanized PVC Stainless Stec)
Not Cased Other.
d. Secondary Casing Telescope Casing Liner Surface Casing Diameter in.
t' Seaoneary Casing h4wenai Black Stee! Galvanized E-- C S ain!ess Meal Other
18 l letnoc of Construction. Repair or .ubandortmen; Auger X(,abl_ Too! Jetted Rotary Sonic
Combination iTwo at Ivinre hiethoasi nand Driver, lViall Point. Sand Point) Nydrauiic Point i0irect Pushl
Horizontal Drllino Plugged by Approved f-Whod Other :Les-.mbe,
19 Proposed Grouting lnterval for the Primarl. Seconcary. and Additional Casing
From Ta Sea! Material t Bentgnile Nest Cement Other __ }
From To Sea! fvtarriat:. Bentoni;e Neat Cameni Other
From To Seal filatenal f Beworrile Neat Cement Other
From T C Seal Material ; Benmrite Neat Cameni Other
Indicate total numbei of existing -wefls on site _ List number of existing unused .veils ant site -_62
21 Is this well Or any existinqtve0 or water tali dr vial on the ovrners comiounus property covered under a ConsumprivelWaler Use Permit iCUPA44sPi .
or CUPAPIUP Application, Yes No rf yea complete the tollomng' Gv�hVUP No. District Well ID No.
:-atitude _ Longitude
2r Data Obtained cram iSPS '\'dap Survey Datum N.=D 27 NAD 8-' kVGS 84
` - 1247—
+y.,atJra of Gcntrr,-t - isc_rs? r-.o. - Signa:vz of C tqr or A,gen: Dale
":pre;:rr. -Qaie H/.=i.eg:st Aparma,
Vie' Jt .?C21 GS +�:G
..' 2�. 73J
s T41�S PERMIT'IS NOT VALID UNTit. PRODERLy StGNSD n Aid AU'HOPIZEQ OFF';CER pR RE?RESEhTA :'!\'E O� THE `{v7dJ CP. ^ELEGAT,p.yUTHt?RfTr i F;;
i) J �_FAIIT SI^,nLl BE AVAILABLE AT THE WELL SITE DURING ALL CC)NSTRiit:TICT! REPAIRMODIFICATIOP: OR ABANDONMENT AGTiVIT1=5.
l` OE =er.•n &e'-532.900i i) incorpmrated is 52-552AOba, FI C Effective Dal= O;:t�oer' 2i'� e3ge f of 2
FILEo�
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SOUFNWWFLOOM WATMA NIAGENDRasrrcr
2379 BROAD STREET. BROOKSVALE, FL 34W4-M
PHONE (3S2) 7W7211 ar (MM 423.1476
VV W.SWFV MD.STATEFLUS
ST.J0IMS9WWWA=ALA M6E1�0WlFAff
4049'REiD STREET. PALATKA. FL 32178-1429
PHONE: (380) 329.4M
VWM.SJR AaCOM
M0ffnft ESTFI.Q�WA M NVAR6lMR05MCT
152 WATER MANAOERIENf OR., HAVANA, FL 32333.4712
1 (U.S.1LW way 90.10m rmdofTWbhome)
PHONE• {?w) wg4M
VYMW.NWFVAAD STATEA:US
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3301 GUN CLUB ROAD
WEST PALM BEACH, FL 334164880
PHONE (501) 686' 4 MW
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9225 CR 49
LIVE OAK R. 32060
PHONE: (385) 382-1001 or 221P10M (Fb M@ odi)
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FILE CUry DEC 182018
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STATE OF FLORIDA _ Per 2� �OJ8
�b DEPARTMENT. OF' IMALTH t`Gu� 10
ONSTTE SEWAGE TREATMENT AND DA
'ti 4CG N0 SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ ,i�] Ne'w S s t
PERMIT NO.
DATE,PAID:
FEE PAID:
RECEIPT It
Y em C ] P,3"sting System [ ] Holding Tan]c [ . ] Innovative
C 1 Repair C ] Abandonment [ j Temporary [ ]
APPLICANT:
AGENT: TELEPHONE: S6 Lucie Count
MAILING ADDRESS:
I �
TO BE.COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED '
BY A PERS023.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) IF REQUESTING -CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
-- _
PROPERTY INFORMATION --- --
te O
LOT: ) BLOCK: SUBDIVISION: (� P�i/](�,S UnEr O,•)y PLATTED: .
PROPERTY1 ID ZONING: I/M OR EQUIVALENT: [ Y / N ]
PROPERTY!'SIZE:
A � ACRES WATER SUPPLY: [�] PRIVATE PUBLIC [ ]<=2000GPD [ 1>2000Gi?D
IS SEWERiAVAILABLE AS PER 361.0065, FS? [ Y ,/ I] DISTANCE TO SEWER: '� FT
PROPERTYI ADDRESS: �Q0�-U�j C
DIRECTIONS
TO PROPERTY:
-0 17k C �01M" -6 /� c 7-
�
Ala?"
f lG,5
o 2� a w C� n�('. 00 c�
i
—��&o
BTJILDING INFORMATION
,,jj
[JC] RESIDENTIAL [ ] COMMERCIAL
Unit Type of
.No Establishment
No. of
Bedrooms
Building Commercial/Insti.tUt'lonal System Design
Area Soft Table 1, Chapter 64E-6, FAC
C� 'v /Ml
2.
4
C ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE:
DATE:
DH 4015, 08/09 (Obsoletes previous editions which•may not be used)
Incorp ra ed 64E-6.001, FAC
DEC I 8 i•
It
FILE,C6py
Page 1 of 4
a
ra �
I
'STATE OF FLORIDA PERMIT �k _
DEPARTMENT OF HEALTH-
] ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM .SPECIFICATIONS
APPLICANT:I AGENT:
LOT:BLOCK: SUBDIVISION-
-3
PROPERTY, ID If- [ Section/Township/1'arcel No. or Tax ID Number ]
TO:BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MLTST;PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY.S2ZE CONFORMS•TO SITE PLAN: [ YES [ ] NO NET USABLE AREA AVAILABLE: Q,10 ACRES
TOTAL, :ESTI�JA.TED SEWAGE FLOW: 3,o o GALLONS PER DAY [RESIDENCES -TABLE 1/OTHER-TABLE2 ]
1UTHORIZED�. SEWAGE FLOW: GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: 0 ® 'S QF T
BENCHMARK/!REFERENCE POINT LOCATION: �(1�.rJ %,4/ 4144
ELEVATION !OF' PROPOSED SYSTEM SITE IS [ 1WHES / FT ] [ XB04E / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM -TO THE FOLLOWING FEATURES
SURFACE WATER:An FT DITCHES/SWALES: 7-5, FT NO LY WET? [ ] YES [ NO
WELLS: PUBLIC: p m FT LIMITED USE: C7ii FT PRIVAT�:�FT NON —POTABLE ��� FT
BUILDING FOUNDATIONS: AD FT PROPERTY LINES:_zi-�LFT POTABLE WATER LINES: �, /FT
SITE SUBU' CT .TO FREQUENT FLOODING: [ ]. YES A NO 10 YEAR FLOODING? [ ] YES NO
10 YEAR•F�OOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
ay1J` YMU1!',1.1.z 11.Vk'Uk(M&XlUN SITE 1
MfJNSELL ][/COLOR TEXTURE,
USDA SOIL SERIES:
DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
OBSERVED WATER TABLE: INCHES [ABOVE/BELOW
ESTIMATEDiWET SEASON WATER TABLE ELEVATION:
HIGH WATER TABLE VEGETATION: [ ] YES X] NO
SOIP.TEXTURE/LOADING RATE FOR SYSTEM SIZING:
DRA NFIELID CONFIGURATION: [ ] TRENCH [ ] BED
REMAKE{S/ADDITIONAL CRITERIA:
SOIL PROFILE INFORMATION SITE 2
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO.
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
r] EXISTING GRADE. TYPE : [PERCHED / APPARENT ]
_ INCHES [.ABOVE/BELOW ] EXISTING GRADE
MOTTLING: [ ] YES [] NO DEPTH: INCHES
DEPTH OF EXCAVATION: INCHES
[ ] OTHER (SPECIFY)
- f /
SITE EVALUATED 5 DATE
DH 4015, 12/11 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC Page 3 of. 4