HomeMy WebLinkAboutSURVEY, APPICATION SEWAGE DISPOSAL1.
_ STATE OF FLORIDA
-� 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. �� % —/F� SAINT LUCIE County Health Dep mant
--
Section I I 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 plan).
3. Proposed location of septic tank must be shown on
plan.
4. Any end or stream areas must be indicated on the
plan.
Section II I Information:
1. Propeirty Address (Street & House No.)Diflne Or;
Lot 1 7 A Block Subdivish
Date Platted Directions to Job
Driv'o to Property 250' on
2. Owner or Builder A J T ConStru
P. O. (Address City
Septic; tank system to be installed by:
717r�
3. Specifications:
gallon tank with
square feet of
drainfield with at least 4" inside diameter pipe. 3
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 speci-
fications and attachments will be constructed in ac-
cordance with state requirements.
Applicant: _
Signature: _
Section III -
Installa
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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 and give this
office a 24-hour notice when ready for inspection.
on
Scale 1" = 50'
( Rear)
THIS PERMIT EXPIRES ONE ) "11V
YEAR FROM DATE OF ISSUA4z,/ &y
0/6 rN
Permit VOID if well or septic
'v:tem is installed in a location
o'her than area permitted.
PRIOR HEALTH DEPARTMENT
APPROVAL REQUIRED
DRAINFIELD TO BE INSTALLED
WITHIN THE SPECIFIED FILLED
AREA. ^ . /_ J- ,
PIe se Print (Front)
�y/�✓ (Name of Street or State Road)'
C2(�l Date: 7/d
DO NOT WRITE BELOW THIS LINE * + a • a + + • + + + + + a
)Iic�ation Approval &Construction Authorization
subject to following special conditions:
The aboI s'Ai ed} application has been found to be in compliance with Chapter 1OD-6, Florida Admi istratlt've Code,
and cons y Ij) is hereby approved object to the above specifics ions an conditions. // G
G / o
By: C County Health Dept. «� C Date
Y R • • i * /Y' • • • Y ! Y Y Y # R Y • Y Y • ♦ # • • • Y # # • # 9 # • • # Y #
Section IV - Final Construction Approval
Construe tion of installation approved:
Date:
FHA Nod.
*#*««1********a
SAN 428
REV. 3/75
Yes No
By:
VA No.
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CERTIFY THAT THE PLAT SHOWN HEREON IS A
TRUE AND CORRECT REPRESENTATION OF A SURVEY MADE
UNDER MY DIRECTION AND THAT SAID SURVEY IS
ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF
AND THAIT THERE ARE NO ENCROACHMENTS EXCEPT AS
SHOWN. '
- - E —
, REGISTERiu VEYOR LAND gn
FLORIDA CERT NO 3169
W. J. SCHQEPFEK
1671 THUMB POINT DRIVE
FORT PIERCE FLORIDA 33450
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ERTIFY THAT THE PLAT SHOWN HE-P=C'! S
ORRECTREPPESENI-ATDfNOFASU�z.'=,/, _
DIREC'[ION' Af!D THAT SAID =
f_O THE BEST OF P,1Y KNOWLE[)C.E =i v _ _ --
HERE ARE NO E,NICROACHMENTS E." _
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