HomeMy WebLinkAboutAPPLICATION - SEWAGE DISPOSAL FACILITIES'I STATE OF FLORIDA
II
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
DIVISION OF HEALTH
Post Office Box 210, Jacksonville, Florida 32201
!' APPLICATION AND PERMIT
! OF
INDIVIDUAL SEWAGE DISPOSAL FACILITIES
Application / Permit
No. L'Hbff-,:8) A SAINT LUCIE County Health Department
Section I Its Instructions:
1. Percolation test data, soil profile and water table ele-
vation 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 iplan).
3. Prop'osed "location of septic tank must be. shown on
plan.'
4. Anyiipond or stream areas must be indicated on the
plain.
5. Indicate name and date of plat of subdivision. If not
platted, attach metes and bounds description.
6. Complete the following information section.
NOTES:
1. Not valid if sewer is available.
2. Individual well must be 75 feet from any part of
system.
3. Call W-s-aa and give this
office a 24-hour notice when ready for inspection.
Section Ills- Information:
1. Property Address (Street & House No-) SE corner of Bartow and Cassia
Lot. Block 86 Subdivision Unit 9 Indian River
Date Platted Directions to Jobs On USn'9., t0 EHSy $ ♦�E On
Non Cassia to Prop. on SE Corner of Barton and Cassia
2, Owner or Builder Ed Blum
P. O'. Address City Fort Pierces F
Septic tank system to be installed by:
Scale 1" = 50'
(Rear)
3. Specifications:
`%5a gallon tank with
'1A U square feet of
draipfield with at least 4" inside diameter pipe.
i
4. Hodse-to be constructed:
Check one: FHA VA
Conventional
!
This is to'certify that the project described in this
application, and as detailed by the plans and speci-
fications and attachments will be constructed in ac-
cordance with state requirements.
Applicant' Ed Bluth
Please Print
Signature:
IVY
THIS PERMIT EXPIRES ONE (I(
z
YEAR FROM DATE OF ISSUANCE
Permit VOID if
°
N
,,Olt
c/f cr'�^°IC
s stem is installed in a fo atIon
other than
area
PRIOR pern-Ihtcd.
HEgLTH
o
APPROVAL: REEPARTMENT
QUIRED
DRAINFIELD TO BE INSTALLED
WITHIN THE SPECIFIED FILLED
a
AREA.
germ%�� o23gas
a
z,
d
3
0
m
X
0
a
JED
(Front) / lt CI County
(Name of Street or
/S
tate Road)/
Date:
* • * • * * • * * • * * DO NOT WRITE BELOW THIS LINE * • + * + + + * * * * +
I //
Section III - pplication Approval & Construction Authorization
subject to 'following special conditions:
The ab ve signed application has been found to be in compliance with Chapter 10D-6, Florida Administrative Code,
and'' n truction �Iher ap oved, subject to the above specifications and ponditions.
By: i County Health Dept. Date 3 a3'0 %8
R • + • * * • • N N • N N N * • N N ♦ N N ,• N N N • N N N • * * N • * • * •
Section Final Construction Approval
Construction of installation approved: Yes, No
Date: By:
11
FHA No. VA No.
* • R N ♦ R N N • + • • * • • • • • • ♦ • ♦ f + * + N • N Y • * ♦ f • Y + +
SAN 428 !
REV. 3/75