HomeMy WebLinkAboutD O H SEWAGE DISPOSAL FACILITIESApplication/Permit
No. /IA/h O -lGil
County Health Deoartment
r�
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
DIVISION OF HEALTH
Application and Permit
of
Individual Sewage Disposal Facilities
Section I - Instructions:
1.
Percolation test data, soil Pro-
file and water table elevation
information must be attached.
(Note: Test must be made at
proposed location of system).
2.
Existing building and proposed
buildings'on lot must be shown
•
and drawn to scale at their
location or proposed location.
(Use block on this sheet or
attach plot plan).
r •' 3.
Proposed location of septicr.,
'
tank must be shown on plan.
4.
Any pond or stream areas must
d h 1
5. Indicate name and date of
recording of subdivision. If.
not recorded, attach metes and
bounds description.
6. Complete the following infor-
mation section.
Notes:
la.- Not valid if sewer is available
i2. '"•Individual, well must be 75 feet
from any part of system.
3. Call 4�61-5350 and give
i' this office a 24-hour notice
j wh'en°ready for inspection.
be indicate on t e p an.
^ Section Ih - Information:
'.� 1. Property Address (Street & House No.) Kirby Loop Road
Lot 4 Block Subdivision Pine Vista
Date Recorded:6-3�- Directions to Job 'or <On M
2.,
aressC,,,
cations
SCANNED
yY� Taaik Drainfield BY Scale 1" = 50'
Gals. ft. of 6" clay the St Lucie County
or 5" perforated `7 (Rear)
plastic drain in a
I 3' trench or z TpTS PERMIT EXPIRES %
l
Gals. ft. of 4" clay drain w
IV or p" perforated m
plastic drain in an o
16" trench-
:,4. House to be constructed: "
.Check one: FHA >o m
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M VA —� Conventional t'u
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Thi5;is'.to certify that the, project M I W
w DRAIN FIELD TO BE INSTALLED a
1 describ$d in this application, and as r rt
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detailed by the plans and specifica- m WITHIN THE SPECIFIED FILLED' m
f tions`,anA attachments will be con- AREA. z
F strutted in accordance with state a �D erlp 72� a
requirements.
Applicant: Marcus Benzin' (Front)' "
;Please Print _ (Name of Street or State Road) /' ,.r• �
,
Signatgre: �-k - Date:March 29, 1978 ,
* `* * * * * *. * DO NOT WRITE '•BEtOW THIS LINE
Sectibn'III- Application Approval -&,Construction Authorization -
Installation subject to 'following.special,conditions:
I --f-i��.�lk�oa� to b�. ��'yo 16�c, ��1-,Aa, 5'i"N: hzlo�a tl•�. c ro:� n� oE�th� a„� � .. , .
-�_: The'abov signed application has been 'found to be in •compliance with .Chapter 17-13,i "
'Flori a Admint israti Co e,,,and construction is hereby approved, subject't`th,e
&bb pecifi ion nd: onditions. '.
t..
County Health Dept'. Dates
61
Section.:I - Final Construction Approval '-
-CorVFuction,of installation approved: .,Yes No
Date By: ..
• .FHA No.' - VA No.
TEMPORARY
SAN 428,
iii REV. 7/1/ 3