HomeMy WebLinkAboutAPP PERMIT FOR SEWAGE DISPOSAL FACILITIES.-M Z .
_ DITARTMLNT OF HEALTH AND TO;HADQJTATIVE SERVICES
DIVISION OF HEALTH
� � •..I om» w. ago �...w.wr. ��..u. aaxl � -
A licat'ion and Permit
jl of
Individual Sewage Disposal Facilities
Application/Permit
No.C/* �Q-3/� S% �G�C%E County Health Department
Section I - Instructions:
1.
Percolation test ata, soil pro-
5.
Indicate name and date of plat
file and water table elevation
of subdivision. If nbt=.platted,
information must be attached.
attach metes and bounds description.
(Note: Test must be made at
6.
Complete the following infor-
proposed location of system).
mation section.
2.
Existing building and proposed
buildings on.lot must be shown
Notes:
and drawn to scale at -their
1.
Not valid if sewer is available.
location or proposed -location.
2.
Individual well :rust be 75 feet
(Use block on this she-et'or _
from any part of system.
attach plot plan) .
3.
Call li'6/- S3S0 and give
3.
Proposed location of septic tank
this office a 24-hour notice
must be shown on plan.
when ready for inspection.
4.
:,ny pond or stream areas must be
indicated on the plan.
Section i1 - Information:
1. Property, Address (Street & House No.)
Lots Zs*Z6Block P Subdivision
Date Platted OG D Directions to
2. Owner or nuiiaer �96�
P.O. 'iAddress7e9ity_
Septic tank system to be inst
{
3. Specifications:
gallon tank with
�—square feet' of
dF&Bifield with at least
4" inside diameter pipe.
4. House to be -constructed:
Check one: FHA
VA- ✓ Conventional
This.is to certify that the
project1described in this
application, and as detailed
by the plans and specifica-
tions and attachments will be
constructed in accordance with
state requirements.
z
a
B
cD
O
I•D
w
fi
N
/ o
Applicant: .92
"Z G Cis%! z 0)
Please Print `+
job 5. o.v LS"'ST
'L.Sa c V.P. 3A6't
PiE.PG E
Scale 1" = 50'
(Rear)
U
SCANNED
BY
St Lucie County
z
3
0
0
1-b
f1.
K
o
M
rr
0
It
w
c�
rt-
w
m
0
w
a
(Name of ,Strr et or State Road)
Signature--�% '^� Date: �/ li
********************** DO NOT WRITE BELOW THIS LINE ********************
Section III - Application Approval & Construction Authorization
Installation sun3ect to following special conditions:
I. ... _ .a_ i__ ._— ,. ,, ,A D,,.,, ....�._ ice_
THIS PERMIT EXPIRES ONE ())
YEAR FROM DATE OF ISSUANCE
Permit V010 if well or septic
system is installed in a Iocation
.other than area permitted.
PRION HEALTH DEPARTMENT
• M.......
! effnil-7:;"0Lla�
DRAINrII L-a I ;:INSTALLED
WITHIN THE SPECIFIED FUEQ
AREA.
The above above signed a plication has been found to be in compliance .
with hapter OD , Florida. Administrative Code, and construction
is eby a r e , ubject to the above specificati s and condi �o�s s
BCounty Health Dept.*�f Date -_i� *t
*********
Section V - Final Construction Approval
C' struction`of installation approved: Yes No
D' te: - By:
Fgn Nn. VA No.
***
SAN 428
REV_ 3/75