HomeMy WebLinkAboutD O H PAPERWORKSTATE OF.,.FLORIDA , -,, , PERMIT it
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICESDATE PAID
ONSITE .SEWAGE „DISPOSAL .SYSTEM FEE PAID $,
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter,381, FS & Chapter 1OD-6., FAC_
CONSTRUCTION PERMIT. FOR:..
New System [ ] Exi-sting System [ ] Holding Tank
[ ] Repair '[. .] Abandonment [ ],.Other(Specify)
APPLICANT: aV4 &OfMS arvtn7Df1 _ AGENT: DAI]
PROPERTY STREET ADDRESS: [.Uda/pad
LOT: BL0 K: SUBDIViSION:E. 1/2 of N.E. 1/4 Of N.W. 1/4 Of S.E. 1/4 of Sec. 'C04
i
PROPERTY ID #2 rr SECSTION TOE*NSHIP/RANGE/PARCEL NUMBER]
I I[OR TAX ID NUMBER]
SYSTEM UST BE. CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
]EXPIRE LONE YEAR FROM THE.DATE OF ISSUE: HRSAPPROVAL 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..
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SYSTEM'bESIGN AND SPECIFICATIONS
[ ] Temporary/Experimental
exm�� :7-P q%D30797
T
[
J fGALLONS
/GPD]- SEPTIC TANK/AEROBICUNIT
CAPACITY MULTI-CHAMBERED/IN
SERIES:,[ ]
„ A.
�
[
] FGALLONS
/ GPD],�
CAPACITY MULTI-CHAMBERED/IN
SERIES:[ ]
N
[
J GALLONS.
GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK.: 1250 GALLONS]
K
j'-"1
] GALLONS
PER DOSE DOSING TANK CAPACITY
DOSE RATE ] PER 24 HRS NO. OF
PUMPS: ]
D
R
A
I
N
F
I
E
L
D
O
,T
._ H
E
R
] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
] SQUARE FEET UrObStDJCted ls"ItwEN am
SYSTEM: [ ] STANDARD ( ] FILLED
GURATION: [ ] TRENCH [X ] BED
[ ] MOUND [ _ -
�
N OF BENCHMARK: Trams' P07rn rew NX Coates' (see Plot Plat)
ON OF PROPOSED SYSTEM SITE [ 6 ] [INCHES/FT] .(ABOVE/BELOW] BENCHMARK/REFERENCE POINT
OF DRAINFIELD TO BE [ 18 J [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
REQUIRED: [ 3 ] INCHES EXCAVATION REQUIRED: [ 72 ] INCHES
SPECIFICATIONS BY: �''TITLE:
.r. T
APPROVED BY: 1 -� a., �k.1 TITLE:
DATE ISSUED:
:
`zA i
HRS-H Form 4016, Mar 92 (obso(etes previous editions which' may'not be used).
(Stock Number: 5744-001-4016-0) -
APPLICANT
F'r 0 Sic
S (, CPHU
Ci EXPIRATION.DATEL:G:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER:
Permit tracking number assigned by CPHU.
APPLICATION FOR:
Check Itype of permit, if "Other" specify type in blank.
`?
APPLICANT:
Property owner's full name.
TELEPHONE:
Telephone number for applicant or agent. -
_
AGENT:
Property owner's legally authorized representative.
r,
MAILING AbDRES_S'.
P.O. box or street mailing address for applicant or agent.
LOT,'BLOCK, SUBDIVISION or
PROPERTY M#:
27 character id number for property.. (CPHU may require property appraiser ID p or section/township/range/parcel numl
%``..
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:.
Minimumspecifications from Chapter 101)-6, FAC. '
DRAINFIELD:
Minimum specifications from Chapter IOD-6, FAC.
OTHER:
Other specifications, such as operating permit requirements, tow -volume push toilets, variance provisos.
SPECIFICATIONS BY:
Name of individual providing specifications. If designed by a registered engineer must be sealed:
APPROVEDBY:
'' County -Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED:
Date_ permit is issued by CPHU.
EXPIRATION DATE:
One year from date issued if the system has not been installed. Permits for system repairs becomevbid. 90 days from that
issued.
r
\,
X]
AGENT:
'STATE OF FLORIDA PERMIT #'
b-- DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE. PAID Z)
ONSITE'.SEWAGE DISPOSAL SYSTEM FEE PAID
APPLICATION FOR CONSTRUCTION,PERMIT RECEIPT,#
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
ON FOR:
System [ ] Existing System [ ..} Holding Tank.
it [ ].Abandonment [ ] other(Specify)
Drawdy Brothers Construction
Culpepper & Terpening, Inc.
[- ] Temporary/Experimental
TELEPHONE:(561) 464-8160
ADDRESS: PA. Box 13360,Fort Pierce, Florida 34979-3360 99d3 %8q
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].
E. 1/2 of N.E. 1/4 of NA 1/4 of S.E. 1/4 Sec. 5, T. 36 S., R. 40 E.
LOT: -h BLOCK: SUBDIVISION: DATE OF
.SUBDIVISION' N/A
.PROPERTY ID,.#: c [Section/Township/Range/Parcel No..] ZONING:
CD
PROPS IY SIZE: 4.7 ACRES '[Sgft/43560.], PROPERTY WATER SUPPLY: [ ] PRIVATE EX ] PUBLIC
PROPERITY STREET ADDRESS: Midway Road.
-]
DIRECTIONS TO PROPERTY: South Side of Midway Road at Jorgensen Road
4
BUI. G INFORMATION [ ] RESIDENTIAL [X ]. COMMERCIAL
Unit type of No. of Building # Persons Business Activity
No Establishment .Bedrooms Area Saft Served For Commercial Only
I
1 Office Building 4254 8 Office for cat ructial Carq>ahy
2
P,. 4
[O1 ].?Garbage Grinders/Disposals ],.Spas/Hot Tubs ) Floor/EquipmentDrains
[0 ]`Ultra -low Volume Flush Toilets [ ] other (Specify)
APPLI6ANT'S SIGNATURE: /�,.�/ .�� DATE:
HRS-H Form 4015, Mar 92.(Obsoletes previous editions which may notbe used) Page 1 of 3
(Stock NuTber:-5744-001-4015-1)
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT,BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION
PROPERTY ID#:
PROPERTY SIZE:
WATER SUPPLY:
PROPERTY ADDRESS:
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, stateand zip code tailing address for applicant or agent.
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, acopy
legal description or deed must be attached.
Official date of subdivision recorded in county plat books (month/day/year) or date lot originally recorded. Dividing an
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 p or section/township,range/parcel
Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and pre
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes,
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and eascmeni, with nosubsurface ob
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 county.
lot
road
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
'I
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter IOD-6, FAG Examples single family, single wide mobile home, restal lIrant,
doctors office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routm:l) provide sleeping accommodations fol�
occupants.
BUILDING AREA: Total footage of enclosed habitable area of dwelling unit, excjuding garage, ra, ,a exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each store of struct.re I I
i
it
N PERSONS: Number of persons residing, using, or working in establishment. For residential esablishment, 2 persons per bedroom
i
assumed. III
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hour; .I opere'.on, or other information required) bt
Table II, Chapter IOD-6, FAC.
I
FIXTURES: I+farkeach listed fixture with number installed or 'NA" if not applicable
SIGNATURE: Stgnatur of applicant or agent. Date afplication are day submitted to the CPY.0 w ith ap, ro, nave Res and inni hmems I
ATTACHMENTS. A it ',n .min to scale, showing bo,n-'Fries dimen
c.ae sewage disposal ez7 _ s , ° t-.. a, , ,.,rr
features, filled areas, obstructed areas, and surface water. Location of wells,ronshe sewage disposal systems, surface waters) and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot. II
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a Boor plan showing the square footage of the establishment, all plumbing drains and fixture types,and m
features necessary to determine composition and quantity of wastewater.
STATE OF FLORIDA PERMIT S �%
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE .DISPOSAL 'SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Dmidy &-o&m GonstnCt1D11. AGENT: Culpepper & Terpe dm, Im.
,LOT: BLOCK: SUBDIVISION: E. 1/2 of N.E. 1/4 of N.W. 1/4 of S.E. 1/4 of Sec. 5 J. 36 S,
PROPERTY ID S: 5-36-40 [Section/Township/Range/ParcelNo. or Tax ID. Number]
1-
TO -BE C,MPLETED BY ENGINEER, .HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDEr REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTYY SIZE CONFORMS TO SITE PLAN: [X] YES [ ] NO NET USABLE AREA AVAILABLE: 4.7 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 636 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORI'ZED SEWAGE FLOW,: 11,760 .GALLONS PER DAY [1500 GPD/ACRE°OR. 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1,964 SQFT UNOBSTRUCTED AREA REQUIRED: 1S6A SQFT
BENCHMAff/REFERENCE POINT LOCATION.: Traverse POirt at N.W..1/4 (see Plot Plan)
ELEVATION OF PROPOSED SYSTEM SITE IS f�, J-1N ES FT] [ABOVE BELOWCj--SEN FERENCE POINT
THE M1
SURFAC
WELLS:
BUILD]
SITE 5
10 YEA
SOIL P
Munse
MUM. SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
WATER: 75 FT 1 DITCHES/SWALES: 75 FT NORMALLY WET? [ ] YES IX NO
'UBLIC: 200 FT LIMITED USE: IM FT PRIVATE: 5 FT. NON -POTABLE:', 50 FT
FOUNDATIONS: 7 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 10 FT
EJECT TO FREQUENT FLOODING: [ ] YES.] NO 10 YEAR FLOODING? [ ] YES [X] NO
FLOOD ELEVATION FOR SITE: FT MSL/NGVD .SITE ELEVATION: N/A FT MSL/NGVD
Not in a flood vay
:FILE .INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
Texture Depth
Gino C�...i Q--to n,-2-!L—
1,hitn �_to .Pll
Gino M! tom
Fire RM-0
to
to
to
to
USDA 'SOIL SERIES:'. 2 Ankorn Sand
Munsell #/Color Texture Depth
to
to
to _
to
to
to
to
to
USDA SOIL SERIES:
helot 60"
OBSERVED WATER TABLE: • INCHES [ABOVE ELOW
GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: 17 INCHES [ ABOVE BELOW' EXISTING GRADE-.
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING -]-YES [ ] NO —DEPTH: INCHES
.SOIL TEXTURE/LOADING RATE FOR SYSTEM .SIZING; 0.65. DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [X ] BED .[ ] OTHER (SPECIFY)
i f1 .,....yv
REMARKS/ADDITIONAL CRITERIA: "_'"""`^"ar...
SITE EVALUATED BY:
HRS-H Form 4015, Mar 92 (obsoletes previous
(Stock Number: 5744-003-4015-1)
1t
U
Page 3 of 3
INSTRUCTIONS:
PERMIT N:
APPLICANT:
AGENT:
LOT, BLOCK, SUBDIVISION:
PROPERTY ID#:
PROPERTY SIZE:
Permit tacking number assigned by CPHU.
.Property owner's full name.
Property owner's legally authorized representative.
Lot, block, and subdivision for lot.
27 character number for property. (property appraiser ID N or section township/range/parcel number).
Check if property size at site conforms to submitted site plan. Record net usable area available -lot area:,
all paved areas and prepared road beds within public rights -of -way or casements and exclusive of streams,
normally wet drainage ditches, marshes, or other such bodies of water.
of
SEWAGE FLOW: Record the estimated sewageflow for the establishment from Table 1 (residences) or Table 2 (non-residend 1), Chapter
I OD-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (I �i gallons
per day per sere for private water supplies and 2500 glad per acre for public water supplies). If authorizedII
wage flow
does not equal or exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA:
BENCHMARK INFORMATION:
MINIMUM SETBACKS:
FLOOD INFORMATION:
SOIL PROFILE INFORMATION
WATER TABLE:
SOIL TEXTURE:
DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION
ADDITIONAL CRITERIA:.
SITE EVALUATED BY:
ELEVATION WORKSHEET
BENCHMARK
[+] SHOT:
[I:I.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be At least
limes as large as the dainfield absorption area and at ]"at 75 percent of the unobstructed area must meet minimum
setbacks in Chapter IOD-6, FAC. The unobstructed am must be contiguous to the dainfield. 11 +
Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Recur the
elevation of the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can bemeet to all listed features. Actual measurements must be recorded13r 'NA"
for non applicable features. Features on site plan or within 75 feet of the applicant lot must be measured. Tjra location
of any public drinking well within 200 feet of the applicant's lot must also be verified. 4
Record information on lot's subject to flooding. For lots. subject to flooding record 10 year flood elevation for site and
actual site elevation. a i{
Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. ISoil
identification will use USDA Soil Classification methodology (Mansell colors and USDA soil textures). Refusals must
be clearly documented, Provide USDA soil series if available, record "UNK" if the series cannot be dem I I ed.
Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wetseason water ableelevation based on site evaluation, USDA soil map, and
historical information. Indicate if them is high wear able vegetation present. Indicate if mottling is presenl'and depth.
Record soil texture or loading ate for system sizing.
If applicable record depth of excavation required. Record "NA" if not applicable.
Check dainfreld configuration required. If other, specify type.
Record any additional remarks pertinent to site or installation. Ex. dosing required..
Signature of evaluator, title, and date of evaluation. Professional engineers must sea] all documentation
ELEVATION OF'BENCHMARI / REFERENCE POINT IS:
SITE 1 _ SITE 2 SITE 3
H.I.
[-] SHOT I-] SHOT [-] SHOT