HomeMy WebLinkAboutD O H PAPERWORK.li(frE3ffrnP.xlr.'iyt..(7yloHF�►I,1`Edj�J�tiilTylEMP,LOYEE.,,rGOR�JOTHER„GQUAI.IFIED, PERSON. ENGINEER'S MUST
'ROVIDE'=REGISTRATION NUMBER.lAND i SIGN BAND 1 SEAL EACH:PAGEbOF.r,SUBMITTAL... COMPLETE ALL ITEMS.
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'ROP,Ff(;;'.f b,{,,En`h'O)!i$ORNS,s.'17.E]ix�ITFe:dPLA,Nn ]r:G a ziYE$, ;,_.i[ I„] .NO s;lG•.NET,IUSABLE tAREA AVAILABLE: 40,1 ACRES
'OTAIIgESTIMATED7rSEWAGE', FLbWG"dai oli?&010111 snGnsGALLONS :PEA0DAYDA1[RESIDENCES-TABLE 1 / OTHER -TABLE 2]
WTHO fs1'.EIYicS'E{'i)L�Etd�`i.0�^171sG 7sa ti¢g, o zaitorsut 1 6AI.Bbt7S IPEIt nDAY cL'�(}1500 6PD/ACRE OR 2500 9PD/ACRE]
I'n p� , n f5p ( 9d w ��rf e' a, s:. rS rnn + nh '� 5m .,t , n.P •.
fNOBSTR�CT�D,. �rA fA�{I2�1SLnE:' •�SQFT UNOBSTRUCTED AREA REQUIRED: � SQFT
[INCHES/`,J-) /BELOW.] BENCHMARK/REFERENCE.POINT
CHFy •1711;,I�� atSkFlii S1 'e- siC r$ ,�A]A;?'IT7]INEDl FROM,sTHE,sPROP�OSED�;SYS,TEM,��,'0 THE,, FOLLOWIRGA7EATURES •
iURFACE WATERi > %-.�ZuriRMd sdl m(wolsd'iDIICCHES/:SWALES:In%:+/. f:a:IvmgFT ]p :iNORMALLY WET?. [: ]AYES [�O
AELY.S:.. PUB}4dI, Zop FT', ..LIMITED USE: /?D FT PRIVATE: j %S FT NON -POTABLE: S`a FT
iUILDINGmf.0UND� T1ONS,:uasolli I..%A .M EMi b`4ROP.ERTY MINES.:ae dJdlsz I:u=ulir MOTABLE WATER> LINES:Z. 2,Zril.,tw FT
.L9latnsln sddzumlfpl lssilgge ad]lp ims 2V uidfivi a anir, an+• Jo-.f rel pldcsi?g.1mrIi lnfi
iITE .SUBJECT=F'1�U'Q�I.i]�'�]I. �Ip f�a1�I0YES1• •, [„Ogllb nlldvr( ync'n IOIIYHAItI FLOOD3NG? [ ] YES [ HO
�l
LO YEAR FLGOD.,ELEVATION FOR'SITE: FT MSL/NGVD. SITE ELEVATION: FT MSL/NGVD
Jul h6iavolo bopOt;suT Of bimm eliibanr} w ]as[dy-.o ,:,1 ::,.•::•: '" . r. r �z z']ol j I, ncomoulm Linos£} / : 1 + r i lr'
!ineiSvIy1J 7GnIJ' Ann �tiJ '
;OIL PROFILE INFORMATION SITE 1 SOIL PRi5OFILE INFORMATION SITE 2
lip2 iu Mtn 02U191 ]O i 11 alp d1q:,b mulnirli a o] fSIG nm'a• +. qt n sd�.md•!'v I''''mrt �i :� LJi �; . 6 . - ... _. .. ,.,..._
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USDA SOILISERZES: .;. ,,, ,,.,
' AifiCE .^�Yi,." _
USDA USOZL SERIES:,.
• it, wq1 41¢J9: 9MM34Vt.':
s v] vtir_Az nOdu> •. • -n " m,ilrt,uvfln 0ir)di n:r„{. gad_! ; / PPI AjPARE
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)BSERVED WATER TABLE: % 3D INCHgES'[h7� / BELOW] EXISTI G GRADE. TYPE: [•F 4NT]
=IMATED WET.'SEASON WATER,TABLE ELEVATION: INCHES [ ABOVE /'BELOW ] EXISTING GRADE.
. .p nu .l , pb xd , G !alzni In o��, ,......, . . I';ca' ;b,s' ^^ b'lor^R "" 'I iRi' lA1'+.; r :,,•,
iIGH'WATER"TABLE VEGWEAWOt�.: [ ] SS [ ] NO MO$TI,YN6": �[-i, ACES [ ] NO DEPTH: INCHES
OILsj2%��Z2.�R'�FIFIoS�tEM' ° ..�r (�fG'Jal`blabhni:,Z(]il }u1F laysfDEPTH'lOF EXCAVATIONtNC T':<U..VA'+'PIHES
�`T
IRAINF.I=Lp_0 rxc-,(R8+I0w: ' r ,] T ED Y]__j,,^OTHER; (SPECIFY)
20
tEMARRS/ADDITIONAL CRITERIA: .r._ 20'X>s`� ,f
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To'6 ' a O}1'l.:. }�.IPA
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TE-EVAWATED'BY DATE:"
as.. page'-3-ofi 3
11015 f0m (Replace s if H Form 40 5 LPape 31 wnoi moy Ehi v`e����: '
Ila Number' 57M-003-�075-7) _
STATE OF FLORIDA
PERMIT if
DEPARTMENT OFF HEALTH
DATE PAID
ONSITE DISPOSAL SYSTEM
• FEE -PAID $.(73
.SEWAGE
APPLICATION FOR CONSTRUCTION PERMIT
RECEIPT. if'
Authority:' Chapter 381, FS 8 Chapter 1OD=6, FAC °'�'-""'=?''`+�`•'- -
APPLI TION FOR:
[, New System [ ]�Existing System ' [ ] Holding Tank
['. ]''Temporary/Experi'meutal
[ J Repair [ ],Abandonment [ ] other(Specify)
UAN EQ
APPLICANT: •"
HAyZoLp ve> _A
TELEPHONEV' BY
',
.
•:..
AGENT: 'ry (LEU.':-..E.,,�,!/.tZ:IC. BYO-/r�,"
MAILING ADDRESS: 66 .r f /�!_.. 11n4 ff-!Q/Gf r�46,
-------------------------------------------
TO"BE CONPLETED'BY';APPI'ICANT OR APPLICANT'S AUTHORIZED AGENT.
ATTACH:BUILDING PLAN AND TO -SCALE
SITE PLAN`SHOWING'•PERTINENT" FEATURES REQUIRED BY CHAPTER 1OD-6,�'FLORIDA°ADMINISTRATIVE CODE.
------------------------------
PROP.ERTY'INFORMATION [IF LOT IS -'NOT IN A RECORDED SUBDIVISION,
ATTACH�'LEGAL-DESCRIPTION OR DEED]
VISION
MEIIR
U
rD i ;P- ` •a" `' �`•" [section%Townstiip/Range Pac91 No,] ZONiN6: ,
PROPERTY SIZE:./ o y ACRES [64ft?/63560] PROPERTY WATER
SUPPLYt -[4••PRIVATE [ ] PUBLIC
P'
PRORTY STREET, ADDRESS: -Pb
.
DIkECTIONS TO PROPERTY: rsr�
•..--.:�-i.•�,.. -"
// lI A'�Nt A
r.
BUILDING INFORMATION I [' ,' i;.RESIDENTIAL [ ] COMMERCIAL
_ lRE
Unit Type of No.3of Building ,if Persons musiness Activ ty,
No Establishment .-' Bed ooms Area Seft Served -For Commercial`.Only
1 SiNG i�r F4....
2 _.
31, .. -
• i.
(h�q"Garb'$ge'Grinders/Disposals '' [i%] Spas/Hot'Tubs [/ oJeFloor/Equipment Drains
Ultra=low Volume;Flush•Toilets':. WO] Other - (Specify) '=•-�
APPLICANT'S"BIGNATURE =:.0 a''�<••2.,.,'.�-..-./-�'�-�f .'• '� .DATE �'-� ����Q 9
`3
P) which may beusea)r- ! - ..•Page 1 of 3
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TO'+BE COMPLETED BY'i.ENGINEER; 7HEALTH UNIT '•EMPLOYEE,zOR'OTHER'QUALIFIED PERSON. ENGINE ER''S MOST
PROVIDE �'REGISTRATIONM1NUMBER'"AND•,iSION-AND'SEAL EACHn PAGE`OF `SUBMITTAL{.t7 COMPLETE ALL ITEMS.
r _:;. +iu tON......a_eiG see; :. :. n. .:a .• _ ,,:
AUTHORI ZED j SEWAGE.1,FLOW :..: r: .><, , . •
UNOBSTRUCTED +AREX AVAILABLE:tl
BENCHMARK/REFERENCEI.POINT•:LOCATION:i
ELEVATIONn'OF''PROPOSED,'SYSTEM SITE��IS
•LI.1:}l•[Ii1U:I:I 111 ' -- ...•• Lj If;,5.1]
7S [ ] NQ NET USABLE AREA AVAILABLEs _In - ACRES
•vo7;,;,.7Y,o.]'�C Nyr'L•lab+n..n9 Mit:./..R 1...-1-
il1LLONS PER,'DAY -,•:[RESIDENCES-TABLE 1 / OTHER -TABLE 2]
y.. ..G �.. ..
,ALLONS, PER -:DAY _c.0 0.._GPD - OR 250D, GPD/ACRE]
iQFT ('•-f=UNOBSTRUCT - IRED: SQFT
POINT
THE MINIMUM SETBACK ICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:'
s M1n '> 1 itN-,DI.,r.HEt.. T., ,• n c• r,.., ,r - : t(r+tu ,r! �1.
SURFACE WATER: FT �. , i otodDo TC•HES/SW S FTC OR ,MATZY WET? [ j YESr NO
WELLS: PUBLIC: kITED USE:1 iZ j PR,V T,a�) rFT NON POTABLE. FT
BUILDING FOUNDATIONS: FT' PROPERTY LIKES: .—/— FT POTABLE WATER LINES: FT
tr a.:. an-rc•c •r .w:c:+�he•+u un cv !eio M1U S _ .. ..A ✓:.r: I I
S_.•. so -.a 'd :,.it lcd rn>:a;lq.l,': :.a c.r:n.S.n•nua•en nsht p!ib rto ;nu:s_1-:-c:r.a s!4 ni� rb^-; 'l ::: '
SITE• SUBJECT.ITO rFREQUENTiJFLOODINGa in [ c] U1 is �a NO_r-,,, DI(duq •(e91,10 aYEAR 'FLOODING? ] YES, NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MS7L'/NGVD
.-_+il9t;:'1-ae'tD!bma.r..•r.,n*7t•)7-e•T�t:r110(?oq .zn`-bnr.a ,.]L.•t, v,ito! n,"G,_ ,•g:r bm^_i '.i(1Jii hl `.-,��/;... r:
SOIL PROFILE INFORMATION SITE 1 SOIL•PROFILE INFORMATION SITE 2 ''`••
USDA SOIL SERIES:
.re r.: ;� �,,;iDe •tln�o :(r a
.: sc .,
al M1vr.
u .- a •L*: lbr ,-,.
;io3r
L
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to
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�• USSDADA SOIL SERIES:—
OBSERVED WATER TABLE:1�5 INCHES �C[ABOVEtI% ELO 2STING `GRADE:' TYPE77 PERC$EDa-)�- PARE ]
11
ESTIMATED WET SEASON WATER TABLE'ELEVATION: E INCHES [ ABOVE HELD ] EIISTI E.
HIGH WATER TABLE VEGETATION-YES7(u[{]0NO•I'c""'gin MOTTLING':n+[�"+,]'=.-YES -y�] N EPTH�:'j{%?:1�J ny"irIINCHES
SOIL`l-TEXTURE/LOADING+eRATE I FORo SYSTEM s+SIZING :c•+-rya 'm1(.]o LY; 7IIEP.TH, OFF EICAVATZI N".! (.1/IONCBHES
DRAINFIELD CONFIGURATION: [ _ 1, T?_ENCH _.'*bC1 BED/[. j_ [ ] OTHER (SPECj,FY)
r
1130
SITE�EVALUATED BY `=z".l P)
_
..I
'i?2 I !
/. DATE:
Y;
DH 4015, 10/96 (Repl ceehl SR -Hform 4o15 [Pepe
Number' 5744-0E3-'4015 1)
37 which n)ay� be used)-���`v'
<' `~
-----Page=_3„O
�-
]3
(Stock t
STATE OF FLORIDA PERMIT:#
DEPARTMENT OF HEALTH DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM: FEE PAID
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter381,. FS & Chapter IOD--6.,:FAC
CONSTRUCTION PERMIT .FOR:
New System [ j Existing System [ ] Holding Tank: [ ] Temporary/Experimental
j I Repair [ ] Abandonment.{. ] Other(Specify)
APPLICANT: • • :AGENT:
r '
PROPERTY STREET .ADDRESS:: v I�
rrp
LOT- - BLOCK:: SUBDIVISION: Y " 1.(-U!7(
PROPERTY ID#f [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
(OR. TAX ID .NUMBER)
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER lOD-6,,.
FAC'.. REPAIR. PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE.. ALL OTHER
PERMITS EXPIREONE. YEAR FROM THE DATE OF' ISSUE. DEPARTMENT OF HEALTH APPROVAL OF SYSTEM DOES
NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL
FACTS WHICH' SERVED AS A. BASIS FOR ISSUANCE OF THIS PERMIT REQUIRE THE ;APPLICANT TO MODIFY THE
PERMIT APPLICATION:. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEZNGMADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFICATIONS
T [ ] [GALLONS / GPD) SEPTICTANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED/IN SERIES;]; ).
A [ ] [GALLONS / GPD] CAPACITY MULTI-CHAMBERED/IN SERIES:[
N ( ] GALLONS GREASE. INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANKS 1250 GALLONS)
K: ( ]' GALLONS PER DOSE DOSING TANK CAPACITY' DOSE -RATE [ ] PER 24 HRS NO. OF PUMPS: [ j
D ]:SQUARE FEET PRIMARY 'DRAINFIELD SYSTEM.
R. ( ] SQUARE FEET. SYSTEM
A TYPE SYSTEM:. [ j STANDARD [ ] FILLED (:- ] MOUND [ j _
I CONFIGURATION: [ J TRENCH j= ] BED. [.
N
F LOCATION OF BENCHMARK:
I ELEVATION OF 'PROPOSED SYSTEM SITE [ ] (INCHES/FT. T] (ABOVE/BELOW] BENCHMARK/REFERENCE POINT,
:E .BOTTOM OF DRAINFIELD TO BE ( :` ] [INCHES/FT) [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
FILL REQUIRED:: [ j INCHES
O
T
H
E'
R.
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
EXCAVATION' REQUIRED: [,•
TITLE:
TITLE•
] INCHES
CHO
EXPIRATION DATE:
VH 4018. 10190 (Replacaa HRS-H Form 4016 (Gage I which maybe used), Page 1 of 2
(Stock Number' 6744.001-4016-0):. Building Department
u
INSTRUCTIONS:.
PERMIT NUMBER: Permit tracking number by County Health Department..
APPLICATION FOR: Check type of permit; if "Other" Specify typein: blank.
APPLICANT; Property, owner's full. name.
TELEPHONE: Telephone number for applicant or agent. s
AGENT: Property owner's legally authorized representative.,
MAILING ADDRESS; P.O. box orstreet. mailing address for applicant oragent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: 27 character ID number for property. (Health Department may require propertyappraiser ID# or
sectionJtownship/rangelparcel number,)
SYSTEM DESIGN AND
SPECIFICATIONS;
TANK: Minimum specifications from Chapter IOD,6, FAC..
DRAINFIELD: .Minimum specifications from Chapter IOD•6, FAC.
OTHER: Other specifications,. such as, operating; permit requirements; low -volume flush toilets, variance provisos'.
SPECIFICATIONS BY: Name of individual providing. specifications, Ifdesignedby registered' engineer must be scaled.
APPROVED BY; County Health Department personnel reviewing and approving permit,
DATE ISSUED; Dinopermitis issued by County Health Department:.
EXPIRATION DATE: One. year from date issued if the system has not bean installed. Permits for system repairs become. void 90 days from the
date Issued..