HomeMy WebLinkAboutD O H APPLICATION - SEWAGE DISPOSAL FACILITIESSTATEOFFLORMA -
•. DFRARTMENT or HEALTHDt" RLHADDdTATIVC SERVICES
' DIVISION OF HEALTH
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Application and Permit
of
Individual Sewage Disposal Facilities
t
County Health Department
ection I -Instructions:
1. Percolation test data, soi-1 pro-
file andl. 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).
3. Proposed location of septic tank
must belshown on plan.
4.� •:,ny pond or stream areas must , be
indicated on the plan.
Section II - Information: '
1. Property -Address (Street & House No.) "
bdivision
Lota�F E.! y 3 Block__.�;_St
Date Platted /9S6 D]
_ -
2. Owner or Builder f-.gl
/iit
P.O. Address/6o9 /fib€ S. City' ---
Septic 'tank system 'to be .in.
l
3. S ecifiba-1
;
gal
p Q :gallon. tank with
h a l: • square, feet of
...drainfield with'at least
B.
4" inside diameter•pipe'.
m .
0
4.t House to be"constructed:
~'
Check one: FHA
VAJ'T7 Conventional
it ,
This, is to.,,certify that the,
rr
project described in this
0
application, and as detailed
by the plans and specifica-
tions andlattachments will be
constructed in accordance with
o
state requirements.
W
Applicants �QO/E %%s7U/S
O
a
Please Print
5. Indicate,.name and date of plat
of.subdivision. If not platted,
attach, -metes and bounds description.
6. Complete the following infor-
mation section.
Notes:
1. Not.valid if sewer..is available.
2. Individual well must be 75 feet
from -any -part of ._system.
3. Call ' `!6/- S3SD and give
this office a 24=hour notice
,when ready for..inspection.
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Gr%
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Scale 1" = 50'
(Rear)
SCANNED
BY
St Lucie County
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(Name of Street or State Road)
Signature-��iz'J� Date:FZZ%�
*********I************ DO NOT WRITE BELOW THIS LINE ********************
Section III - U21 ication Approval & Construction Authorization
Installation subject to following special conditions:
St-kr_ 7PW r' 'Tn PAD !36 LCUCL tV /T1� /20Xyb 4,eauxd
The above signe application has7been found to be in compliance .
wit Chapter 10� 6, Florida -Administrative Code, and construction
is ' reby a o e ,."subject to the above specific £i ns�and cond'ti
By:t County Health Dept. ��Date 3 d 7
Sectio V - Final Construction Approval
THIS PERMIT EXPIRES ONE (I)
YEAR FROM DATE OF ISSUANCE
Eertnit VOID if w'dl or se^iie
'! i is installed in a location
other than ,,,rea permitted.
PRIOR.,HEALTH DEPARTMENT
Apmn= P.Fnilir,'Fn
DRAINFIEJ_D TO BE INSTALLED
WITHfN•THE SPECIFIED FILLED
AREA.
inerm L+ 7t C23
47hstruction of installation approved: Yes No
Date: By:
FFA Nn_ VA No.
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SAN 428
REV. 3/75'