HomeMy WebLinkAboutD O H SEWAGE DISPOSAL FACILITIES)' :Application/Pern
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County Health Department
DEPARTMENT OF HEALTH-AND,REHABILITATIVE SERVICES
' DIVISION_ ;OF' -HEALTH ,(l,
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Application and -Permit
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-Individual'Sewage
Disposal Facilities�� '
Section I - Instructions:
:
1.
Perco,latinn- test data, soil pro-
S. Indicate name and date of
'
file'�and water table elevation
recording of subdivision. If
ilnformation must be attached.,,
not recorded, attach metes and .,
(Note: Test must be made at
bounds description.
proposed location of system).
6. Complete the following infor-
2.
Existi'ing building and proposed
mation section. ;
buildings on lot must be shown
and drawn to scale at their
Notes:
location or proposed location.
.1.1 Not valid if sewer is available.
(UseJblock,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 '461-5350- and give
tank
must be shown on'plan.
this .office a 24-hour notice
4.
Any
pond or stream areas must
ywhen..ready„for inspection.
be indicated on the plan.
`
Section II,'- Information.-
,1.
Property Address (Street & House No.)
Corner „Off'-MOhaw and Rrgant RnAd
Loth&n-7 Block _5B •.:S.ubdivisibn
San Lucie Plaza
Date;Recorded 11-2-25 Directions to
on
JobNort.h on 01d llixia. Wga+'. nn} ^+•,Luei,e
2.
South Mohawk
Owner or Builder Alvin -'Bos'nnberry
P.O. Address 3210 Iraquoi$C:tlye port.
-pi Prn�y Flnr+Aa c
3.
Specifications
Tank Drainfield
Scale 1". = 50'
!
Gals.___ ft. of 6" clay tile
or 5" perforated
_
(Rear)
plastic drain in a
3' trench or
Q6 ft. of 4" clay drain
z
_Gals.
on, 4" perforated
D
pl`astic'drain •in .an
o
Fh
18" trench
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A. House:to be constructed:
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Check one: FHA
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VA X Conventional
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This,is!to certify that'the project
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de$cribed in this application, and as
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detailed by the plans•and specifica-
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tions al¢¢'d attachments will be con-
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structed in accordance with state
requirelents.' • •
Appli
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Signa
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ItAly nr'Bossenberrg•'
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JPlease Print (Name of Street or..State Road)'
IY2: Q.�/�r� �`` -,Date •.
DO,,. NOT WRITE .BELOW THIS'.LINE * * �, * ,* *. *, * • * *.''* .�* * 1N `.
t ,III -'Application ApprOyal &Construction Authorization'Y
+a'3'l afi nn cnhiaci- to Fnl'l nwinn an'Pni a.T enndi f-i nnc'•' t.
Flo q:t tint owzrTnal:� cry' cro��ar�r.c ?tea Y,.,
Th ve si ed `ap 7Cod
io ' }tar been, found to be in; compliance with, Chapter
Flo ida Adm' istra P.
d construction is hereby ap roved,�sub3ect tab w'ec' icati on itions YI, ounty'Health Dept. N 0to
'Section IV „ F1nal _Constructioh Approval
Const ctio ;pf installation approved ;• Yes _ ',,. k - No
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,. Date ;; By:
.. FHA No;. VA No
TEMPORARY ,a k;," i.�1 'ti e -' ,r •J ,,.r,'rij`'
SAN 428'
REV. 7/1/73