HomeMy WebLinkAboutAPP SEWAGE DISPOSAL - SEWAGE DATA SHEETNopM _ /S'5r it
STATE OD MRIDA '
DEPARTMENT OF HEALTH AND REHADHATATIVE SERVICES
DIVISION OF HEALTH
►.M ofM D 9W J•chronalb. /br4� oYJol
Application and Permit
of
Individual Sewage Disposal Facilities
ST GG/C/E County Health Department
Section I - Instructions:
1. Percolation test Eta, 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).
3. Proposed location of septic tank
must be shown on plan.
4. Any pond or stream areas must be
indicated on the plan.
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 L6� S�Sd and give
this office a 24-hour notice
when ready for inspection.
Section II - Information:
1. Property Address (Street & House No.)
Lot Block Subdivision
Date Platted oL,J Directions to
2. Cwher or
P.Q. Address/DY CyPL/SCEOity_
Septic tank system to be inst
Goo.�E
3. Specifications:
7'C22 gallon tank with
square feet of z
drainfield with at least
4" inside diameter pipe. tD
4. House 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 specifica -
tions and attachments will be
constructed in accordance with
state requireements.
Applicant: 'FoeA42P �oGleT�'EY
Please Print
Signature:
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�E �ESC�/�T/oiy EG a �u
lob zSTo Lt�c1r L.
o.0 Ltl� f✓ LA.
Scale 1" = 50'
(Rear) �e{(n3 'D\
�. z6�' o•c E. 792' o�
-7'd
TOM PERMIT EXPIRES ONE (IT
YEAR'FROM DA
-°VOIp if �^ell or eeptic
inst'lled'ermitted ion
e°her than area p
PRIOR HEALTH DEPUIR DENT
APPROVAL REQ 1N
DRA�NFIELD gpECIF1ED FILLED.
WITHIN THE
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(Name of Street ppr State Road)
Date: Z /7f? �6�4PlPlED
********************** DO NOT WRITE BELOW THIS LINE ******************
SectionApplication Approval & Construction Authorization St Lucie Count,.
Installation subject to following special conditions:
The abol'e- `signed appl:c ion has-been tound to be in compliance .
wit hapte - F1 . da,Administrative Code, an construction
is a eby ov subject to the above specifica sand condi io s.
By; County Health Dept. Date a
SectioF
inal Construction Approval
ion_ of installation approved: Yes No
By:
_ gVA No.
***************************************************************************
SAN 428�
REV. 3/75
�County Health Department
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES-,•
DIVISION OF HEALTH '
Application and Permit
of
Individual Sewage Disposal Facilities
DATA SHEET
Locotion: C �s9vE ;Applicant: Ird/a/!zO GDl;/C'7iyES'
County:
NOTE: This septic fork system is not located within 50feat of the high wafer line of a lake, stream, canal or
other votes, nor within 75teat of any. privater well; nor within 106feet of any public•woter aupply;
nor., within 10 feet of, water supply pipes; nor within 100 feat of any public'eewer systea'l.
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Plot plan must show
data
all required in
'and
2(a)
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} `oll••oth'er pe tirr 0-N
ZS'
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V data.
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3.
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V4 -4A)7-
PLAN' .
-
SOX DATA
L EGEND '
0.
Drainage Pattern
F I
�CL/fsSZ
7
t _
— Pro osed Se fie Tank and
' p
Drainfield
to 2
G %
®Proposed Water Supply Well
��
3
SgNO
QExisting Water Supply Well
14
®Soll Boring and Percolation
Test Location.
0 5
0 7.
o
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V_
B
SOIL BORING'
LOG
?
S'
Sail Identification: CLASS
GROUP
Soil Characteristics 5ZE. Z
P6f
Percolation Rate Z min/inch
Water Table Depth �z
CERTIFIED BY:
Water Table Depth ii
During Wet Season 36
FLORIDA PROFESSIONAL No. ` ZD
Compacted Fill Of /Qy R-eq= //u PLtJCLr
Z' 2 %
� S
�p
Dale Job No.
Compacted Fill Checked By: ,/P
Dote�y�7T B
Sheet of '