HomeMy WebLinkAboutD O H PAPERWORKSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATION
SCANNED
BX
APPLICANT: Black Street Enterprises, LLC
CONTRACTOR / AGENT: R.R011ins UCI@ OUI1
LOT: 4/5 BLOCK: 46
APPLICATION # AP966438
PERMIT # 56-SF-1144982
DOCUMENT # SE819397
SCANNED
SUBDIVISION: ID#:1428-702-0938-000-6
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROV:
REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [XIYES [ ]NO NET USABLE AREA AVAILABLE: 0.48 ACRE:
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [ I RESIDENCES -TABLET / OTHER -TABLE 2
AUTHORIZED SEWAGE FLOW: 720.01 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE
UNOBSTRUCTED AREA AVAILABLE: 2000.00 SQFT UNOBSTRUCTED AREA REQUIRED: 1000.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE
INTERSECTION OF ST. LUCIE BLVD AND IROQUOIS AVE
0.00 [ INCHES I / FT ] [ ABOVE I / BELOW ] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: N/A FT DITCHES/SWALES: 23 FT NORMALLY WET: [ ]YES [X]T
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: 89 FT NON -POTABLE: N/A i
BUILDING FOUNDATIONS: 20 FT PROPERTY LINES: FT POTABLE WATER LINES: N/A 1
SITE SUBJECT TO FREQUENT FLOODING? [ ]YES IX]NO 10 YEAR FLOODING? [ ]YES [X]E
10 YEAR FLOOD ELEVATION FOR SITE: FT [ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVL
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
USDA SOIL SERIES:Lawnwood sand
Munsell #/Color Texture
Depth
1 OYR 6/1
VF Sand
0 To 10
1 OYR 7/1
Fine Sand
10 To 20
1 OYR 5/4
CMN/DST RF
20 To 48
1 OYR 6/4
Sandy Loam
48 To 60
USDA SOIL SERIES:Lawnwood sand
Munsell #/Color Texture
Depth
1 OYR 511
VF Sand
0 To 12
10YR 7/1
Fine Sand
12 To 24
1 OYR 5/6
CMN/DST RF
24 To 40
10YR 613
Sandy Loam
40 To 54
1 OYR 7/2
Sandy Clay
54 To 60
OBSERVED WATER TABLE: 60.00 INCHES [ ABOVE
/
BELOW
] EXISTING GRADE
TYPE:
[ PERCHED / APPARENT
ESTIMATED WET SEASON WATER TABLE ELEVATION:
20 INCHES [ ABOVE
/
BELOW
]
EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ]YES [
]NO MOTTLING: [ ]YES
[ ]NO
DEPTH: INCHE
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Fine Sand/0.60 DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [X] BED [ ] OTHER (SPECIFY)
7 RMalRKS/ADDITIONAL CRITERIA
SITE EVALUATED BY:
INCHE
DATE: 05125/2010
Duncan, J4gLy,(Title: Environmental Specialist II) (St. Lucie County Environmental He
DE 4015, 08/09 (Obsoletes previous editions which may not be,used) Incorporated: 64E-6.001, FAC Page 3 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: BLACK STREET ENTERPISES, LLC. AGENTS
.aST HALF OF LOT
f
, 4 AND 5 Kt 46 SUBDIVISIONS SAN LUCIE PLAZA UNIT ONE
PROPERTY ID /: 1428-702-0938-000-6 [Section/Township/Range/Parcel No. or Taz ID Number]
ssaaasaasssaasaaaas¢¢axsaaasaaasaaaanaaxassasassassasssasss¢saaaxssasaasssaassssaasasassa
TO BE -COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND BEAL RACE PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
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PROPERTY BIKE CONFORMS TO SITE PLANS [ ] YES ( ] NO NET USABLE AREA AVAILABLE, ACRES
TOTAL ESTIMATED SEWAOE FLOWS GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 21
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY (1500 GPD/ACRE OR.2500 GPD/ACRE)
UNOBSTRUCTED AREA AVAILABLE: SQPT UNOBSTRUCTED AREA REQUIRED: •. SQFT
(SITE BENCHMARK ONE)
SENCHMARK/REFERENCE POINT LOCATIONS ASSUMED 100.00 FEET ON TOP OF THIS NAIL
ELEVATION OF PROPOSED SYSTEM SITE IS 0.5 [INCHES AHO BELOW] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES,
SURFACE WATER: 75 PT DITCHES/SWALES: 15 PT NORMALLY WET? [ ) YES [ ] No
WELLS: PUBLIC: 200 PT LIMITED USE: 100 PT PRIVATE: 75 FT NON-PoTAELEt 50 FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 10 FT POTABLE WATER LINES: 10 FT
SITE SUBJECT TO FREQUENT FLOODING:
10 YEAR FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE 1
[ ] YES [ ] NO
FT MSL/NGVD
IMpnsell f/Color Texture Depth
to
to
to
to
to
to
to
to
to
USDA SOIL SERIES:
30 YEAR FLOODING? [ ] YES [ [ NO
SITE ELEVATIONS FT MSL/NGVD
SOIL PROFILE
SITE 2
_ Texture
Depth
to
to
to
to
to
to
SOIL SERIESt
to
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED '/ APPARENT]
ESTIMATED ''WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIDE WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZINGS
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ]
RENARRS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
ON 4013. IOM (Replaces MR" Fotm 4015 [Pogo 31 ~ mey be u"d)
(Stock Ns bsr.. 5744003,4013-1)
BED
DEPTH Or
[ ] OTHER (SPECIFY)
INCHES
, 05/04/2010
Page 3 of 3
06/25/2010 09:02 7724096764
CHAUNCEY & WILLIAMS PAGE 01101
PERMI
APPLICATION TO
WON Pam":
CONSTRU
T, REPAIR, MODIFY,
• OR
ANDON A WELL Fee Amaad:
St. Lucia County Health Deparhnetttt �e team
uat be eomplatYd by the Date:
EnvlronrnentalHealth—WererProgrelns Cartltbd
11contractorforapprrval CUPIWUPIk
5150 NW MI4)ar Ddfa Pon St Uhds, FL 349M prior,
well conatn4otlon.
97Y1971 F Td-�893
0, Nome of Pmwt Owno: Uymer Mail"
F2..
AddressClly l9aN Zip QFrel prAntl na4.
6" 9uhdy: Name. 6dC4 NO.. W NO.)
y G
ad Orlltny ..OnvaCtu n aw n9 Adumes
C y ( build 4.p unurt-mvRo. diar ceN d.
..........n.,,.«.�..'..7.rrr..«.............._..«...........
.....................A10
............................... ........._...««.........._.........................
S. PROPOSED WELL: �Now..... ❑ Mphoelrwnt
r �a.._._.....
Abandonment ❑ OIMr,
Rik ,
6. WELL TYPE: OSingle Family Drinking
❑ Single Femlly Irrigation
❑ DOH Public Drinking polio w < is Service can
lesatllon 25 PWPW or BusYlass does not corlelana webt) -WUP Regtd vd
❑ DEP'Public Drinking p is SeMm Connections orsay
25 pati jeorme e)-WUP Redul ed
❑ Commercial Irrigation WUP Required ❑ Mo
❑'
-
.................................................._......................_......................«...«.......«.««....................,........................._......
•' "• ' •,
- Orb OtlI M (t Main):
7. SITE ISON: ❑ SEWER 0 SEPTIC PRO
ED DISTANCEr�-TKyO CLOSEST'SEPTICOR PUBLIC SEWER LINE:
S• CUP/WUP: Is a Water Use Permit (WUP) regtAred
❑ YES Ono (RYES WUP must be attached)
8• CONSTRUCTION METHOD: *!aRt7tary ❑daweTool ❑Other.(Explaln):
10.GROUTINGMETHOO: ❑Beldoriita 20ment ❑other(Expla§I):
11,WELLCONSTRUCTION:2JPVC ❑BlkSteal
❑Galvanized ❑O ther(Explein):
12. CASING DIAMETER (SIZE): Z �� 13. EST TED• TOTAL DEPTH -&SCREEN INTERVAL FROM -aTO Se5
................ ......... .............. ...«..................
_..................
14. PERMR CONDiT10N3: II
.................................... .........................................................:,......
• aL6HDIJha d`v
perms number, and adimafed th a dnpng or abandonment will
before Inldaline drdlarm ndonnrnt sceradom and DronWe^Ih0 dlwdr�eme,`r--
in (Pleaea CO~ an buDOc er dlree y 4 hatarso prim w..rru• m all
wader wen.)• If venatiaolbn dean not Occur and SLCHD if not
onto an-9LCHD IlldpecWr'Neltsrheaft on or after the estimated timB, a nBlnapOCr1
fee will be ww"ad:
..
• Defalydd 61w�an must bs and dhow one ProPosed
1 bca5ott and' hees'b tgBIOB DuA01rIg atrui$ires, property lines, all ermine and
neiphbodng ecp9c sydams andlor Dewar Yves or sewer system ,
I
am all omer apply" eBWedOl Per FltaWa stsaates and FlanWe Admhdatradw: Cade.
♦ Thb
.16. WELL CONTRACTOR PERMIT AGREEMENT. ......*......� 1 OWNERIAGENT.'PERMIf AGGR "i' ' T* ..
EEMENT:
Ibab an
Y aIs list I we. sanpywB) lee PerrwWe 05te a Tide fro, taineda
e weer wo permM errrrrectel recpargv pemdL M needed, wla be oelr+ied
hgaeUle Coda, and nrat ply. that the inldlmaton
r b Wminenpprrnn Of rwyl i tlarey tliell err Oro Ores Of Ilia
Ord that I am donima Of my under
COeabu om IabO celdrr elK eatelbaCts rePNafgq hRwe40E-7lRo Adminlfeatlw Cade (FACT, i ChWW,3 FbriJQft me,tonm&*na aMaaysbandonthe
NICa, end B n aWya setd�e wn ee malnwiwd a yodamov
nrObdein$at`,
fon v WI let O Obtained!
o is app on uanG apgiq ro and oband Ise?r'td ttrllit)p, I Nthw arty
U'r epplbotldn'a eaowaa and MMl..na ea eh»deearr oppr lfrom
l wed:a. I daft end 1 am ea 491M forma OMa. Ow 0a tnramtribn
all tfdrmsvon Artuided an i Omitted is accurate, and tlal l twoinfamad dm tv m of his
rtedera, state, orbml , mo mmiatae ea farad Adow. Omer CdnNaa b panonnal ofthe
9overnmeme. Wed wanype mm ne musts sabmtlea b)ep teaUlCfa One Oadpaed dg"Cy vAedn i UCH
ad any Re.
d a rtfr pe"it e•peabn, whit r occur, Net.
Of a Mrop�rss�aMa/eve Seem to Be. wen Ora. ..
,
0 i
igrabue of woo Contractor Ucenae No.
asse
Dena i ro OrNgefldt SlgnaWro Data
••••••••e_•_•__•.....••.......... DO NOT WRITE BELOW TWIR LIMP -WAD nic cieuf use nu. v
PemdtApprordBY. LJ C - al 1%N
_.a—._,_. _.-._,_._._._.....—._MKMV
Oldanoe m UOaept oap5o OYatBm er newer III)e:
Inepectole Cannerte:
r
vLCHV Rey
Issue Data.
_Grout Materiel:
Db/GO/'Llt1D by:Ue IIL4btJb/b4
Coo•r. Qr Lego!, Nsma Of Prmady Owmf
L.MHUM.CY & W1LL10I11D rM U1r Ua
aERMFI
ISTRU
APPLICATION TO
T, REPAIR, MODIFY,F7gAmo
OR
ANDON A WELL
Thisform
eardlled
prior
ustbscomplatidbyello
II contrsclar for appoewal
o well conatruerlon.
IN~
City! siala
5- PROPOSED WELL: b" ❑ Replacement �i Abandonment JZ Repair ❑ Ofhw.
$1 WELL TYPE: VNStugta Famsy Drtnking
❑ OON Public Drinklog PNOW < is B&rWM CAN
❑ DEP'Publie Drfnitins (> i5 s.wm cwmwcgom i
❑commerciallrrfgation-WUPRda,hed ❑
7. SITE IS ON: ❑ SEWER 54 SEPTIC
S. CUPAWUP:Ise WelerUsePermit (WUP)
9. CONSTRUCTION METHOD: 'X'M:'Momfy
IV. GROUTING METHOD: ❑BentiAte
11,WELLCONSTRUCTION:21(yVC ❑E
en realNe eurila rsl�l 'L �� 13.
❑ Single FAmgy Irrigation
0*mr RAw No.
6s3;
bss flood 29 POOPW or Builflim doze not aonaane eater) - WL P RNOW
-WUP RaralrWd
❑ Omer
-ROPQ BED DISTANCE TO C��L09EST SEPTIC OR PUSUC SEWER UNE C
q ❑ YES 21i0 (If YES WUP muatbe etteched)
❑6ableTool ❑Onrer,(EWAM):
® Cgmant
❑ oaeer (Explain)
Steed ❑Galvanized ❑ Other (Explain):
- -- - ------------------- -
♦ dra Halos,
pwynd nambw, sMl atlhpatad thre dnWig or abandoned va in (ptaaae eontao an Maecldr dlrsdta u hoore odor to drlU:nd go aaMlo drink
water wWW. Irowwaudbn doe¬ =&w end aLCND la nol . and on 9LCND IMpaGiarNdlefla slla M nadir Nre esdmated dme, a reitloped
tee wil be amoaded:
♦ QdtM ill%Aide must be aaaehad and ahow flte proposed i oll bcaem MW d000neas bo oriatb bulding etndfitraa, propmv tries, aU waft and
nelghbodfly aepea syatane andror newer No" or slower oyetem , am eU omer appkeblo emwsce per Fbrwa atftmai wad Floride Adndnlstredw Dodo,
♦This
....................... _............................_.._.........,..._............�..,-................
18. WELL CONTRACTOR PERMIT AGREEMENT:
ItMmyosrWy0arlaaaarripyaralmeepplce0lafWdotTaMao,Fbdda IdaaaUveCode,ar"W
a friar Yee pemw YrnahW rectrrya pemeL N raleped, M tb ordaNrd b opinmenodnenl M.ma
ODInbllMIL I aw oNrfyy0R ap NOW113fehrptbid nRuteaoEa;Fb A 4bCaaVe Co0a(FAC),
ase•A MC, era 02,M PAC, ON be r�YIY,ng'0,�"', 0 abw fc(Eedla ee mN.Ninee a rm4nw
apPOae0an wa to aptl4d AWWd OWWW PrierL'ofner0• iruMw or* dl hVivwow Om Wed en
(hie opmkollon teemeb ON matt aM atrbbjrargapefy Opprw0l from lederN,siste.orboa)
sovarnmme e. Wtll mngyon tepom moat ENDwbedtted bole w4Ykta the aaiepareo apNwy Metln
3D denelMr ddGO Wfi/Osmw awsalbn. whk/leirI oaum 0e6
CoMrscbr /// lkmm MD. 1 / / Dab
Pemdl Approved By.
OMoorrte to emm" saple oystem of lower Una:
Inspectors Cwminei :
•sLCHD
OWNERIAGENT PERMIT AGGREEMENT:
IOM7y eiet I em are erafw dNe pmpnty, tlat lM Yrbnno%
P VAW M aowleb, and than am e+en Of my mporsum" unWr
Cho Mr 373, Fbrida:IMUm. b mralrMirLr pmpety ebunbn Ob
water, I dej* fleet 1 am wen "am IMtne WMW. 04t on Mbonsibd
provided he exurab, wW fW 1 have ink mad fie oww of Ne
rssomwdee diatom alive. Dwwo: "fftbowumalel Ne
DOH ere mpm"Mag a aineas to va "left. ..
i
_ lastoo Dab: � .
3lwl Materiel: —•—•_ _ —.
By-. Dote:
atoHnnae
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