HomeMy WebLinkAboutOWNER BUILDER AFFIDAVIT AND APP - PERMIT SEWAGE DISPOSALNOTICE: OWNER/BUILDERS
OWNER/BUILDERS OF ONE OR TWO—FAMILY UNIT DWELLINGS, OR COMMER—
CIAL BUILDINGS UNDER $25,000.00 IN VALUE, ARE EXEMPT FROM THE
REGULATIONS AS SET FORTH IN FLORIDA STATUTES 468 WHEN BUILDING
FOR THEIR OWN USE AND OCCUPANCY ONLY.
THE SALE OR LEASE, OR OFFERING FOR SALE OR LEASE, OF SAID
STRUCTURE IS A CRIMINAL VIOLATION PUNISHABLE AS A MISDEMEANOR
OF THE SECOND DEGREE.
IN ADDITION, IF THE OWNER/BUILDER DOES SELL OR LEASE THE DWELL—
ING, HE MAY SUBJECT HIMSELF TO A CIVIL LAW SUIT..
I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE
NOTICE ON THE I Z' DAY OF , 1978.
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4-r-;u
OWNER/BUILDER
Application/Permit
No. C Nj R __Z= 4r
_GI�_ County Health Department
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
DIVISION
OF HEALTH
Application
and Permit
of
Individual Sewage
Disposal Facilities
Section S - Inst_r_uctions:
1. P rcol. i-r: test data, soil pro-
5. Indicate name and date of
fiie ,an(! water table elevation
recording of subdivision. If
' information must be attached.
not recorded, attach metes and
• (Note: Test must be made at ,,
bounds description.
proposed location of system).
6. Complete the followinc infor-
2. Existing building and proposed
mation section.
buildings on lot must be shown
- - and drawn to scale at their
Notes:
location or proposed location.
1. Not valid if sewer is available.
(Use block on this sheet or
2. Individual well must be 75 feet
attach plot plan).
from any part of system.
3. Proposed location of septic
3. Call 46",-5350 and give
tank must be shown on plan.
this office a 24-hour notice
4. Any pond or stream areas must
when ready for inspection.
be indicated on the plan.
Section II - Information:
1. Property Address (Street & House No.)Cornier of Kellwood Rd and Lee Blvd.
Lot 3p Block__ subdivision Lakewood Park Unit 5
Date Recorded 10-16-i7 Directions to Job Cornier of Kenwood Rd. and Lee
Blvd
2- Owner or Builder Jose j�h Nelsor
P.O. Addresses 31K0 City Fort Pierce, Fla
3. Specifications
Tank Drainfield
Gals. ft. of 6" clay the
or. 5" perforated
plastic drain in a
3' trench or
z
_Gals.-s_co__ ft. of 4" clay drain
W
or 4" perforated
f0
plastic drain in an
o
�n
1.5' tench
co
4. House to be cc a,
Check one: FHA
m m
cn r-
VA 2 Conventional
— -
re m
p
n
This is to certify that the project
N
r*
described in this application, and as
m
r+
detailed by the plans and specifica-
m
tions and attachments will be con-
¢
structed in accordance with state
requirements.
Applicant: Joseph Nelson
'Please Print
Scale 1" = 50'
(Rear)
THIS F'EMIT EXPIRES 7lIQE m
YEAR EROMDATE _0%Il%UAU E
Perrhit VOID if well or 5
system is installed in a,
Other than area -" "' Perm
PRIOR HEALTH PERM
APPROVAL REQUIF
hAW4. ,__. 10 dE INSTALLED-
WITHIN. THE SPECEED MLE]'
(Name of Street or State Road)
U
0
0
Signature: V' Date: April 4, 1978
* * * * * * * - * * * * * * * DO NOT WRITE BELOW THIS LINE * * * * * * * * * * * * * * *
Section III - Application Approval & Construction Authorization
,4tally ign,subjec.�_to following s.VeciaWconditioW:
G
The above sighed application has been found to
be in compliance with ChAter
17-13,
Florida Administrative Code, and construction
is hereby approved,
subject to
the
above spenc fications and conditions.
By: �r. County Health
Dept. .�—* (�C.%£..
Datej�,]$
Section IV - Final Construction Approval
Construction of installation approved:
Yes
No
Date: By:
FHk No. VA No.
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TEMPORARY
_
SAN 428
;lci hr
REV. 7/1/73
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