HomeMy WebLinkAboutD O H PAPERWORKSTATE OF FLORIDA PERMIT APPLICATION TO CONSTRUCT,
REPAIR, MODIFY, OR ABANDON A WELL
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❑BODUIWe$t PIEASE
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State •ZIP . •Telephon�be,
Lot Block Uni[
Subdlvrsion Check If 62-524: __ Yes _ No
Ze tS—�fcb9 MP_ V�lilp�{Dr`Itiin �Rmail ccm
onNumber E mailAdtlress Tom.
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I7. `Type of Work "n Stare — D ilisbucllon Repair _Modlli ^_Abandonment &'Number of Pmposed Well, ,nw—
9. 'Specify Intended Uses) or Wall($): ncP°b Lbcnravac wabaadmccae
-Z!�Pomestic. Landscape Irrigation Agricultural Irrigation D
._Bowed Water Supply `Recreation Arealrrigation _Livestock Site --Bile Investigation
__Public Water Su ) _Nurse _Monitoring
PPN(Comm Uty or No ryirtigetion Test
—Claw
tic Water Supply (community or NonCommunityrDFp)—ComCo Course
irrigation _Earth -Coupled Goothermat
_-ClassllnJec6on _Golf Course lrtigatlon
HVACSupply SEP
Class VIn1actrom_Rechera _Commerda8lndustriel Disposal_Aquifer_HVAC Return
ReStorage and Recovery_Drainage
mediation: __Recovery—AlrSoarae nx.e.,�_�._.
10,'Distanea fmm Septic Sys(em it s200 R lama Nw cua„e,lw,na,n. pamWlea eye?ica p•rmllag a„p,Jlvit�vnmrel�
fi. Facility DescJription SS ICJ
13'Estimatad Well Depth l��R, •Esdmaled casingDepth 12. Estimated Start Data
.P /� R. 'Primary Ceaing Diameter__IM Open Hole: From__To
14. Estimated Screen Interval: Fmm_To R _fl.
18.•Pdmary Casing Material: _Black Steal �//�� SCANNED
__Galvanized `�'�PVO __Stainless Steel
_NotCased _Other. BY
16. Secondary Casing; __Telescope Casing __ Uner _ Sudace Casing Oiameler
17. Secondary Casing Material: __Black Steel _Galvanized __(n. St. Lucie CIJU)
15•Melhod of ConsWction, Re pair, Of Abandunment PVC .Stainless Suet Other
�/lugar __Cable Tool __Jetted � --
Combination (TWO or Mora Methods Rotary Sonic
__Hodmnlal Dulling _PI ed) Handthod (Well Polnt,Send Point) _Hydraulic Point (Direct Push)'
ug9 byAppmved Method ,OMer (omcnDol
19. Proposed Grouting Interval for the Primary, Secondary, and Additional Casing:
Fmm T0 Seal Material [_aentontto Neat Cement Other
a From
mm—Tc _Seal Material (_ Doctorate— Cement Other
Fmm,�_To__Seal Malarial tBentonite Neat Cement
1
F PTO Seal Material (__Bentanite Neat Cementt her—')
20. Indicate total numberote*ting wells on site )
List numberof adsting unused wells on site 21.•Ishis wellcrany existing well orwaterw�ithd/rawaton the owner's contiguous property covered underaConsumptive/WaterUse Pemhlt(CUPIWUP)
or CUPANUP Application? _Yas �CtJ0 If yes, complete the Longitude following: CUPMNP No.
22. Latitude District Well ID No.
-
28. Data Obtained From: CPS —map. —Survey Datum: AD27 iaaubuvrawrwmoyr,nnan wa aewuanua•a rmnva:uawaacaa..weua rnn ,mm.u,w—'� _NA083 —WG584
�4pmiaWaylarAWaAn'1MnmNM1aaeu...w•..a�... _.....__.__. _ _ _ _ ..
Approval Granted
Fee ReceNad $
Issue Data �,0 , Fxplmum Dalf
Check No.
DEPFome62532500(1) Incorpwaledln62532.40RI),FA.C. EtlodWa Dale: October 7,2010
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Property Card
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Page 1 of 1
Michelle Franklin, CFA — Saint Lucie County Property Appraiser -- All rights reserved.
Property Identification
Site Address: GERMANY Parcel ID: 3229-211-0002- Account #: 161797 Sec/Town/Range:
CANAL RD 000.4 29/36S/38E
Map ID: 32/29X Zoning: AG-5 Use Type: 6000 Jurisdiction: Saint Lucie
County
Ownership Legal Description
Benjamin C Agler
29 36 38 THAT PART OF SEC MPDAF: FROM N 1/4 COR
Karol J Agler
OF SEC RUN S 00 22 25 E 50 FT TO POB;TH CONT S 00 22
156 Mediterranean Blvd N
25 E 842.71 FT,TH S 89.59 54 W 311 FT;TH N 0102 01 W
Port St Lucie, FL 34952
842.71 FT MIL TO S RD R/W LI OF GERMANY RD,TH N 89
47 04 E ALG R/W LI 311 FT TO POB (6.02 AC) (OR 2289-
25I1)
Current Values Historical Values 3-year
Just/Market: $99,624 Assessed: $3,756 Year
Just/Market
Assessed
Exemptions
Taxable
Exemptions: $0 Taxable: $3,756 2018
$99,624
$3,756
$0
$3,756
2017
$81,799
$3,956
$0
$3,956
2016
$62,500
$3,956
$0
$3,956
Date
06-23-2005
02-17-2004
wad:
view: 0
vo-. n,dL• ,
9/62018 4:16 PM
Store: 1
Sale History
Book/Page Sale Code Deed Grantor Price
2289 / 2511 XX00 WD Matthew Lyle Wynne LLC $270,000
1904 / 1362 XX02 WD Carlton (EST) Walter L $1,500,000
Primary Building Information
Finished Area of this building: 0 SF
Gross Area of this building: 0 SF
Roof Cover:
Frame:
Sales Receipt #19750
REPRINTED
St Lucie County Health Department
5150 NW Milner Drive
Port St Lucie, FL 34983
Environmental Health Division
772-873-4931
Item__ # City Price Ext Price
68 - 1 $1115.00 $115.00T
Well Conshvetion
Sublotal: $115.00
Local Sales Taa 0 % Tax. t $0.00
RECEIPT TOTAL: $115.00
Credit Card: $115.00
Visa
59-26790 TBD Germany Canal Rd
Thank You R Have a Good Day!
Exterior Data
Roof Structure:
Grade:
No. Units: 0
Interior Data
Electric:
Heat Type:
Heat Fuel:
Building Type:
Effective Year: 2014
Secondary Wall:
Primary Int Wall:
Avg Hgt/Floor: 0
Primary Floors:
Total Areas
Finished/UnderAir 0
(SF):
J-, Gross Area (SF): 0
c.-iy Land Size (acres): 6.02
Land Size (SF): 262,083
Total Building Count: 1
Features and Yard Items
Qty Units Year Bit
1 520 1999
irrect at this time but it is subject to change and is not warranted.
Lucie County Property Appraiser. All rights reserved.
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ST,ATE 07 FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT P VED
SYSTEM
0C( 00 A
ST. Lucie County, Permitting
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Joshua & Madison Revord
PROPERTY ADDRESS: TBD Germany Canal Rd Port Saint Lucie FL 34987
LOT:
BLOCK:
SUBDIVISION:
PERMIT 4j:56-SF-1870604
APPLICATION #: AP1359965
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1142041
PROPERTY ID #: 3229-211-0002-000-4 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAR ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS
AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E-6, F.A.C.
DEPARTMENT 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
BEING MADE
NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT
THE APPLICANT FROM COMPLIANCE WITH
OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ] GALLONS / GPD Seotic new CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY IMAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps
D [ 500 ] SQUARE FEET
Drainfield new
SYSTEM
R [ ] SQUARE FEET
N/A
SYSTEM
A TYPE SYSTEM: [ ]
STANDARD [ ] FILLED
[X]
I CONFIGURATION: [ ]
TRENCH [x] BED
[ ]
MOUND [ ]
F LOCATION OF BENCHMARK: Site BM red rapped IR in cutout CL of rd towards w property corner
I ELEVATION OF PROPOSED SYSTEM SITE [ 7.00 1 [1 INCHES FT ][ABOVE BELOW BENCBMARE/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 6.00 ][INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
L
D
0
T
H
E
R
ie system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
0 gpd•
ie licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with
64E-6.013(3)(0, FAC.
SPECIFICATIONS
BY: rian a Ingra
TITLE' Environmental Specialist
II
APPROVED BY:
LE: Environmental Specialist II
St. Lucie CHU
Brian J Ingram
DATE ISSUED:
08/31/2018
EXPIRATION DATE:
02/29/2020
DH 4016, 08/09
(Obsoletes all previous
editions which may not be used)
Incorporated:
64E-6.003, FAC
Page 1 of 3
v 1.1.6
A 1359965 SE1092019
f
NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one (21) days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency
Clerk's facsimile number is 850-413-8743.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order will
constitute a waiver of your right to an administrative hearing, and this order shall become a 'final
order'.
Should this order become a final order, a party who is adversely affected by it is entitled
to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are
governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced
by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a
second copy, accompanied by the filing fees required by law, with the Court of Appeal in the
appropriate District Court. The notice must be filed within 30 days of rendition of the final order.
r
HEALTH
.PAYING ON:
RECEIVED FROM
PAYMENTFORM:
St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
PERMIT#.56-SF-1870604 BILL DOC#.56-BID-3914217 CONSTRUCTION APPLICATION#: AP1359965
Kamer Surveying, Inc AMOUNT PAID: $ 515.00
CHECK 2017 PAYMENT DATE: 08/15/2018
MAIL TO: _Joshua & Madison Revord
FACILITY NAME:
PROPERTY LOCATION:
TBD Germany Canal Rd
Port Saint Lucie, FL 34987
Lot: Block:
Property ID: 3229-211-0002-0004
EXPLANATION or DESCRIPTION:
128 - OSTDS Construction System Inspection Research Fee
-1 - Surcharge (All)
-1 - OSTDS New Permit Surcharge
-1 - OSTDS Construction Application and Plan Review, New
123 - OSTDS Construction Site Evaluation
126 - OSTDS Construction Permit (New or Mod, Amendment)
127 - OSTDS Construction System Inspection
133 - OSTDS Construction Reinspection
QUANTITY FEE
1 $
5.00
1 $
15.00
1 $
100.00
1 $
100.00
1 $
115.00
1 $
55.00
1 $
75.00
1 $
50.00
RECEIVED BY: VanceMH AUDIT CONTROL NO. 56-PID3654074
kq
ou 0 9 1'9
STATE OF FLORIDA
DEPARTMENT OF HEALTH ST. Lucie County, Permitting
ONSITE SEWAGE TREATMENT AND DISPOSAL,
' SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[� ] New System [ ] Existing System
[ ] Repair [ ] Abandonment
APPLICANT: Joshua J. 6 Madison W. Revorg)
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] Holding Tank [ ] Innovative
[ ] Temporary [ l
AGENT: KARNER SURVEYING INC TELEPHONE(772) 288 7206
MAILING ADDRESS: 2740 SW MARTIN DOWNS BLVD #333, PALM CITY. FL. 34990
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE
CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS
CREATED OR PLATTED (NM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER
PROVISIONS.
PROPERTY INFORMATION
LOT: N/A BLOCK: N/A SUBDIVISION: N/A PLATTED: N/A
PROPERTY ID #: 3229-211-0002-0004 ZONING: AG I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: 6.02 ACRES WATER SUPPLY: PRIVATE PUBLIC [X ]<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / 0 ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: XXXX German Canal Road
DIRECTIONS TO PROPERTY: SEE ATTACHED
BUILDING INFORMATION [ J] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
1
RESIDENCE 3 2062
2
3
4
[ ] Floor/Equi
SIGNATURE:
DH 4015, 10/97
APPLICANT:
AGENT:
�ther (Specify)
DATE: 8-6-18
Editions May Be Used) ONLINE VERSION
Property owner's full name.
Property owner's legally authorized representative.
Page 1 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
j ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
PERMIT #.
APPLICANT: Joshua J. & Madison W. Revors AGENT: KARNER SURVEYING INC
LOT: N/A BLOCK: N/A SUBDIVISION: N/A
PROPERTY ID #:3229-211-0002-000-4 [Section/Township/Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTEMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINNEERS
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [-4] YES [ ] NO NET USABLE AREA AVAILABLE:0.63 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [RESIDENCES -TABLE 1/OTHER-TABLE21
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1040 SQFT UNOBSTRUCTED AREA REQUIRED:750 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Found Boat S ike West of Gate on German Canal Rd at.E1.100.11 NAVD
ELEVATION OF PROPOSED SYSTEM SITE IS 1.06 [INCHES/ -.] [ABOVE/. ELO ] ENC /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 751 FT DITCHES/SWALES: 151 FT NORMALLY WET? [ ] YES [ ] M
WELLS: PUBLIC:N/A FT LIMITED USE: FT PRIVATE: 75+ FT NON -POTABLE: 50 FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 10 FT POTABLE WATER LINES: 10 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [J] NO 10 YEAR FLOODING? [ ] YES [�] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
SOIL PROFILE INFORMATION SITE 2
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ABOVE / BELOW] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ]
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
BED
DEPTH OF EXCAVATION:
[ ] OTHER (SPECIFY)
DATE:8.6.2018
INCHES
DH 4015, 10/96 (Replaces HRS-H Form 4015
INSTRUCTIONS:
33 which may be used)
Page 3 of 4
PFiRNll#:' Permit tracking number assigned by County Health Department.
• APPLICANT: Property owners fill name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK,SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY 1139: 27 character number for property (property appraiser ID # or sectionhownship/rangelparcel number).
PROPERTY SIZE: Check if property size at site conforms to submitted site plan. Record net usable area available -lot area exclusive of all paved
areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage
ditches, marshes, or other such bodies of water.
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table 1 (residential) or Table 2 (non-residential), Chapter 64E-6,
FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for
private water supplies and 2500 gallons per day per acre for public water supplies). If authorized sewage flow does not equal or
exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA:
Record the square feet of unobstructed area available and the amount required. Unobstructed area must beat least 2 times as large
as the drainfreld absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter 64E-6,
FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION:
Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the
proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be met to all listed features. Actual measurements must be recorded or "NA" for non
applicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location of any public
drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION:
Record information on fors subject to flooding. For lots subject to flooding record 10 year flood elevation for site and actual she
elevation.
SOIL PROFILE INFORMATION:
Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will
use USDA Soil Classification methodology (Muosell colors and USDA soil textures). Refusals must be clearly documented.
Provide USDA soil series if available, record "UNK" if the series cannot be determined.
WATER TABLE:
Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the
estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if there is
high water table vegetation present. Indicate if mottling is present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks Pertinent to site or installation. Ex. Dosing requited.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted.
ELEVATION WORKSHEET ELEVATION Of BENCHMARK /REFERENCE POINT is:
BENCHMARK SITE 1 SITE 2 SITE 3
[+] SHOT H.I. H.I. H.L
H.I. [-] SHOT [-]- SHOT [-] SHOT
STATA OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
ate' SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[� ] New System [ ] Existing System [ ] Holding Tank
[ ] Repair [ ] Abandonment [ ] Temporary
APPLICANT: Joshua J. 6 Madison W. Revor®
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] Innovative
[ l
AGENT: EARNER SURVEYING INC TELEPHONE(772) 288 7206
MAILING ADDRESS: 2740 SW MARTIN DOWNS BLVD #333, PALM CITY, FL. 34990
TO BE COMPLETED BY APPLICANT OR APPLICANTS AUTHORIZED AGENT. SYSTEMS MUST BE
CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS
CREATED OR PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER
PROVISIONS.
PROPERTY INFORMATION
LOT: N/A BLOCK: N/A SUBDIVISION: N/A PLATTED:
PROPERTY ID #: 3229-211-0002-0004 ZONING: AG I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: 6.02 ACRES WATER SUPPLY: PRIVATE PUBLIC-rrl<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / ® ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: =M Germany Canal Road
DIRECTIONS TO PROPERTY: SEE ATTACHED
BUILDING INFORMATION [ J]
Unit Type of
No Establishment
1
2
3
4
RESIDENCE
[ ] Floor/Equipment
SIGNATURE:
[ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
3 2062
[] Other (Specify)
r& DATE: 8-6-18
DH 4015, 10/97 (Previous\Editions May Be Used) ONLINE VERSION
Page 1 of 4
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
S'l±ATE OF FLORIDA PERMIT #.
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Joshua J. & Madison W. Revors AGENT: KARNER SURVEYING INC
LOT: N/A BLOCK: N/A SUBDIVISION: N/A
PROPERTY ID #:3229-211-0002-000-4 [Section/Township/Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTEMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINNEERS
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [-4] YES [ ] NO NET USABLE AREA AVAILABLE:0.63 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [RESIDENCES -TABLE 1/0THER-TABLE21
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1040 SQFT UNOBSTRUCTED AREA REQUIRED:750 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Found Boat S ike West of Gate on German Canal Rd at.E1.100.11 NAVD
ELEVATION OF PROPOSED SYSTEM SITE IS 1.06 [INCHES/ 6] [ABOVE/ EEO.]13ENC /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 75' FT DITCHES/SWALES: 15' FT NORMALLY WET? [ ] YES [ ] vq
WELLS: PUBLIC:N/A FT LIMITED USE: FT PRIVATE: 75+ FT NON -POTABLE: 50 FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 10 FT POTABLE WATER LINES: 10 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [J] NO 10 YEAR FLOODING? [ ] YES [q] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
LYo}*M!j:i*340*A ow00Zil:lSrcY*to) WWYYY:f'J
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
OBSERVED WATER TABLE: INCHES [ABOVE /
BELOW] EXISTING
GRADE.
TYPE:[PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION:
INCHES
[ABOVE
/ BELOW] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO
MOTTLING: [
] YES
[ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
:8.6.20
INCHES
DH 4015, 10/96 (Replaces HRS-H Form 4015
RdSTRUCT(ONS:
311which may be used)
Page 3 of 4
Y �
PERMIT 4: Permit tracking number assigned by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK,SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY IDH: 27 character number for property (property appraiser ID k or section/township/range/parcel number).
PROPERTY SIZE: Check if property size at site conforms to submitted. site plan. Record net usable area available - lot area exclusive of all paved
areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage
ditches, marshes, or other such bodies of water.
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table 1 (residential) or Table 2 (non-residential), Chapter 64E-6,
FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for
private water supplies and 2500 gallons per day per a= for public water supplies). If authorized sewage flow does not equal or
exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA:
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2 times as large
as the drainfield absorption area and m least 75 percent of the unobstructed area must meet minimum setbacks in Chapter 64E-6,
FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION:
Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the
proposed system site in relation (above or below) to the benchmark
MINIMUM SETBACKS:
Record minimum setbacks which can be met to all listed features. Actual measurements must be recorded or "NA" for non
applicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location of any public
drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION:
Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for site and actual site
elevation.
SOIL PROFILE INFORMATION:
Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will
use USDA Soil Classification methodology (Mansell colors and USDA soil textures). Refusals must be clearly documented.
Provide USDA soil series if available, record "UNK" if the series cannot be determined.
WATER TABLE:
Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the
estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if there is
high water table vegetation present. Indicate if mottling is present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. Dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted.
ELEVATION WORKSHEET
ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK
SITE 1 SITE 2 SITE 3
[+] SHOT
H.I. H.I. H.I.
H.I.
H SHOT H- SHOT H SHOT
STATE. OE FLORID #.API�5996
A PERMIT OtZ6-S!7-1870604
DEPARTMENT' .OP HEALTH DOCUMENT- kR137421-3
ONSITE SEWAGE TPYATb=T AND :DISPOSAL; STSTE14
CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE 7XID:06/1512018'
FEE PAX .6f5.00
RECEIPT n:56=PID-3654074
Apmxmm. Joshua& Madison. Revotd
AGENT
Kamer Surveying, Inc
MOPmn ADDRESS 7810 Germany'Canal Rd Port Seint Lucia, �FL 349157
SCANNED
BY
LOT:
BLOCK:
St. Lucie County
sumrnslos!
=9-211-0002-00
-.C3i1ECKZD,
EXI ITEMS ARE NOV IN -COMPLIANCE WITH STATUTE OR. RUM AM MUSr BE CORRECTED_
'TANK INSTALLATION
SETBACKS
1
-3
rpl-I
TANK 97AE [1,] 1090.00 E23
C
1
[2.73
SURFACE WATER 75
rz
E
-]
E023
TANK MATERIAL PolYpropylene
1
3
12al
DZITCHES 75
FT
r
i
r031
OUTLET DEVICE
C,
1
E2 1 9 1 1
PRIVATE WELLS 81
FT
r'
I
t041
4F
MULTI -CHAMBERED. 'ILL� N 3
E
1
(301
IZ13PLTIC WELLS
PT
E
I
E051
OUTLET FILTER folylok PL-611
[
I
r311
IRRIGATION WELLS
-FT
(
1
E061
LEGEND 1. 70-143-I1DC4 2
C:
1
[321
POTABLE WATER 48
(
I
[07]
WATERTIGHT
E
1
[331
BUILDING FOUNDATIONS 7
FT
r
i
rosi
Lawt
(
I
E341']
P86IFERTY LINES, 26
IRT
ragi
DEPTH TO 1.711
(
I
E3S1
OTHER
FT
VRAYNrULD INSTALLATION
FIT.'! D / momm SYSTEM
I
I
Ila]
AREA. m 504 tzl— SQW
E
1
[36]
I)AXINFIELD COVER
[
I
Ell]
DISTRIBUTION BOX —HEADER x
E''
I
r371
SHOULDERS
E
I
[VU
NaMBER OF DRAINLINES 1.6-00 2.
E,
-1
(381
SLOPES
E
1
[131
DRAINLINS SEPARATION
t
1
[391
STABILIZA=N 6271812020
r
]
[141
DRAINLINE SLOPE
[I51
DEPTH OF COVER
ADDITIONAL INFORMATION
[l 6)
ELEVATION 4 ABOVE /
EiE]
3BM 6.0(Y
E
j
140,]
UNOBSTRUCTED AREA
1
U171
SYSTEM LOCATION
1
1
1411
STORbAIIATTR RUNOFF
1
[181
DOSING, raw$
11123
A;Apldq
1
E191
AGGREGATE SIZE,
433
MAINTENANCE AGREEMENT
1
[201
AGGREGATE ExcEsszvz FINES
[441
BUILDING AREA
1
[211
AGGREGATE DEPTH
1:
E4E]
LOCATION CONFORMS WITH SITE PLAN
FILL
) EXCAVATION MATERIAL
.1
].
(463
FINAL .93fTa GRADING
j
t221
FILL AMOUNT
1
11
C47-1
CONTRACTOR
C I
E231
FILL TEXTURE
11
11
1401
OTHER INFILTRATOR Qufck4 EQ36 (srngfe c
1 3
[241
EXCAVATION DEVER
ABANDONMENT
I
E251
AREA REPLACED
t4191
TANK PUMPED
1 1
[261
REPLACEMENT MATERIAL
E
j
r5011
TANK CRUSHED G, FILLED
Comments; Commants are on. page'. 2-
CoksmWCTIOX St Lucie_- CED DATE: 01714/2020
DISAPPROVED fe�
ErIvIm ental.SpOClalis anJ IngIant (ENVIRONMENTAL,HSALTHI
Fnam sxsTzM -St. Lucie, cHD DATE: 001812020
Enviropmentat spectalirka Bdan J Ingram (ENVIRONMENTAL HEALTH)
(Exp,lan tion we Wala6ionu an
r04014n7pago)
DH 4016, 08/,66 (Obsolates all previous editians which may not be used)
Incoxporated:64E-6,003, SAC: Page 2 of 3
EH Database v 1.0.1 AP135$966 - EID1810604
comacents
Tbe system is sized fDr,3 b0droomswith a maximum o=pandy of a
ffw4ado
5T. filter and 0x7lona OF hr Wfpd. No iolatgns, sys(eRl o.k to cover, Contrador notified onsite. Need"nal inspectionfor
ling setback, hiot#id systeg6and ffhal$fte.OrOnq, Ccintra,for Nortbga§tkrnPlumbing
g
iCleaning l-W. KevinWlGreene CFG1428759.
I system approved. Contractor and building departmenternsiled final approval.
DH 403.6, 08109 (Qb&OlotOs all previoud editions whiCh may not be used),
Incorporated; 649-6,003, PAC Page 2 of 3
EH Database v 1.041 AP1359965 E01870604
STATE OF FLORIDA
DEPARTMENT OF HEALTF.--
ONSITE SEWAGE TREAT[
SYSTEM
PERMIT #:66-SF-1870604
APPLICATION #:AP1359965
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1142041
CONSTRUCTION PERMIT FOR: OSTDS NeW}�I��• ��Z—� 1711 SCANNED
APPLICANT: Joshua & Madison Revord i ~_ __ _ _ _ _ BY
PROPERTY ADDRESS: TBD Germany Canal Rd Port Saint Lucie, FL 34987 ZR.Lucie County
LOT:
PROPERTY ID #:
BLOCK:
SUBDIVISION:
3229-211-0002-0004 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT 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 BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ] GALLONS / GPD Septic new CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANX:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps
D [
500 ] SQUARE FEET
Drainfield new
SYSTEM
R [
1 SQUARE FEET
N/A
SYSTEM
A TYPE
SYSTEM: [ ]
STANDARD [ ] FILLED
[X] MOUND [ ]
I CONFIGURATION: [ ]
TRENCH [x] BED
[ ]
N
F LOCATION OF BENCHMARK: Site BM red
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D
0
T
H
E
R
IR in cutout CL of rd towards w property corner
%.00 1 [1 INCHES FT ][ABOVE HELOW BENCHMARK/REFERENCE POINT
6.00 1[ INCHES FT ][ABOVE BELOW BENCHMARK/REFERENCE POINT
w ncyvui U: liD.UU] INCHES EXCAVATION REQUIRED: [ ] INCHES
is system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
10 gpd.
ie licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with
64E-6.013(3)(0, FAC.
SPECIFICATIONS
BY: rian J Iagaa
TITLE: Environmental Specialist II
APPROVED BY:
LE: Environmental Specialist II
St. Lucie CHU
Brian J Ingram
DATE ISSUED:
08/31/2018
EXPIRATION DATE:
02/29/2020
DH 4016, 08/09
(Obsoletes all previous
editions which may not be used)
Incorporated:
64E-6.003, PAC
171?k/
Page 1 of 3
v 1.1.4 - A 1359965 SE1092019
NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such
proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for
administrative hearing must be in writing and must be received by the Agency Clerk for the
Department, within twenty-one (21) days from the receipt of this order. The address of the
Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency
Clerk's facsimile number is 850-413-8743.
Mediation is not available as an alternative remedy.
Your failure to submit a petition for hearing within 21 days from receipt of this order will
constitute a waiver of your right to an administrative hearing, and this order shall become a 'final
order.
Should this order become a final order, a party who is adversely affected by it is entitled
to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are
governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced
by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a
second copy, accompanied by the filing fees required by law, with the Court of Appeal in the
appropriate District Court. The notice must be filed within 30 days of rendition of the final order.
N
R-� rcnan l APPLICATiON,TQ CONSTRUCT, EPAIR-. ...��„
,�_MODIFY, OR ABANDON A MLL
�' '_ ❑SOLLlhwest Pamd{No.�=
o PteA CFILLOUTALLAPPLIGgdLE FIE(.DS3 Flodtle Unique lO •u '+ bND)Rtwest ('Denolos Requtmd FleldaWhem P �—=
n S OSt JOfine RlVer Applicable) Permit Stf gzions Requlieapl°eAliarhed),
O-,SOUth. Floddn, ltrewerer urJl7amncro.ir.arcvn.rdu loromr+kuns .
"
It'"Mr endfonve
❑Sunan)iee River 'LL1pa"^xDPrr^g�nrev,a' --
❑DEP. °�reP°atO `t`)1 0dd'N'^'tb wifcre apoRea6Ia: 62S29 Ouatl No,�_DafnanPan No.
QOelegated Aulho,f fAgplicable)._._.. �P ?'aPMceoon Nu._.
Owher Legal Name if Co - 2 Zp'/
(� ('h�N y CN+ny l ` llr� _ .City... •State'-.- „ T-- — 7 3 %
ZIP'. Telephone Number
S '� Road Na ernumber Cl
Par�IIDNo r )orARemai a Crcl r / _
4 S'1^ �L/G \I C LoF . Block Unil Sed-on or Land rant 'Towns 'Range•Coon —"'�' -
qne'� SubtlMOM - Cheek USZ-524:�Yes._NO
. 'V✓aM�Wen n.....w� _ >d•J Or1'5✓�l, c� G.Gf r. •�...._- "
,Lendscape Irrigation
_:
Recreatfan Aieaamgatfon
_ - r__Golf Course_ irrf ¢Mort ="�1N 'BuPprea,,meom¢rmeL
=c) tyeehod, 9 _HvncseppiY P• 7Class v1611 nRecharge=Com`—HVACRelum=Remedfatfon _Aquffe SlcmgeundRcovery_p(einaga
Recovery—AfrSparga. Other 0'ORncrb fm se)r,nwcN,t.aw
t0 Otstance from SepggSystem if''s21J0 R , an w_m,m`e ° w wiq aepc�y)I
ri i1. Facility Desr�tpgonj 72 Estimated Start Date,__
13.Eslbrfated Well Depth, /j� ft 'Esdmated easingDe lh I`_"p P_^fC •PdmarYCasing DiamataF�.7n, Open Hole: From_To_
14 Esdmaied Screen InfervaL• Fmm__. To
K R:
tS Prfmary C-afng Material.' Black Steel t�/ '�
_Galvanf ed wP.VC _Stainless Sllzel=—Nolcased
1S.Secondary Casing. -_Talescope,Casi "
rl9 —Liner_ Squat. Casing. Diameter_in.._-• -
tYSecondnry,Cas(ngMaledaL __Black Steel
i&'Melhotl ofCansbuopon Repah wAliantlonmenE Ga) Evd'- PVC �_Slairdess Steel _ ()War
,__CombinagonMethods)- —.Augur. ___Cabfu Tool _Jetle_d oMry---"
iTwe or More __Hand V&sr, eR Potn Saud Pc1nt SdnM
_Ho)(mnlalDrilling .Plu edb L ) Hydraulic Point Dlmctgash)
99 y4pmved Mattipt[. ._Other [ommast _ i
mawatelatatnumberofwdsgng wells_onatte )
wegoran e' g - Lstnuelberoregstingunused wells on site..
Y wsgn wellarwaterwithdr waI- lheovmer'ewntiguouapmperlycovemdunderaConsumplry
ortkuds' Up gppltcaRoni'yet
,y�.�j0 If ea, complete the fcllowfng: CUPNJUP. No: Lalbude. _ Y, mp
maanuale LlGT Hydm4glslAppmvaf
Check No. Y
VE OF THE WME) OR DELEGATEOAUMORIIY, THE
ORASANOONME Ar. nncc
CA - Cq: C.h1 f
St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
PAYING ON: PERMIT M56-SF-1870604 13lLLooca56-BID-3914217 CONSTRUCTION APPLICATIONMAP1359965
RECEIVED FROM: Kerner Surveying, Inc AMOUNT PAID: $ 515.00
PAYMENT FORM: CHECK 2017 PAYMENT DATE: 08/15/2018
MAIL TO: Joshua & Madison Revord
FACILITY NAME:
PROPERTY LOCATION:
TBD Germany Canal Rd
Port Saint Lucie, FL 34987
Lot: Block:
Property ID: 3229-211-0002-000-4
EXPLANATION or DESCRIPTION:
128 - OSTDS Construction System Inspection Research Fee
-1 - Surcharge (All)
-1 - OSTDS New Permit Surcharge
-1 - OSTDS Construction Application and Plan Review,New
123 - OSTDS Construction Site Evaluation
126 - OSTDS Construction Permit (New or Mod, Amendment)
127 - OSTDS Construction System Inspection
133 - OSTDS Construction Reinspection
RECEIVED BY: VanceMH
QUANTITY
FEE
1
$
5.00
1
$
15.00
1
$
100.00
1
$
100.00
1
$
115.00
1
$
55.00
1
$
75.00
1
$
50.00
f
AUDIT CONTROL NO. 56-PID-3654074
STATE OF FLORIDA
DEPARTMENT OF HEALTH
'{ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[� ] New System
[ ] Repair
[ ] Existing System
[ ] Abandonment
APPLICANT: Joshua J. & Madison W. Revor�p
PERMIT NO. Jy'SF^I sI % 0(pAy
DATE PAID:
FEE PAID: —�—
RECEIPT #:
[ ] Holding Tank [ ] Innovative
I 7 Temporary [ ]
AGENT: KARNER SURVEYING INC TELEPHONE(772) 288 7206
MAILING ADDRESS: 2740 SW MARTIN DOWNS BLVD #333, PALM CITY, FL. 34990
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. `SYSTEMS MUST BE
CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
IT IS THE APPLICANTS RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS
CREATED OR PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER
PROVISIONS.
PROPERTY INFORMATION
LOT: N/A BLOCK: N/A SUBDIVISION: N/A PLATTED: N/A
PROPERTY ID #: 3229-211-0002-000-4 ZONING: AG I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: 6.02 ACRES WATER SUPPLY: PRIVAT PUBLIC X]<=2000GPD [ 1>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / N ] DISTANCE TO SEWER: FT
PROPERTY ADDRESS: X%= Germany Canal Road
DIRECTIONS TO PROPERTY: SEE ATTACHED
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
[ 'q] RESIDENTIAL [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
RESIDENCE 3 2062
[ ] Floor/Equipment
SIGNATURE:
Other (Specify)
DH 4015, 10/97 (PrevXou� Editions May Be Used) ONLINE VERSION
DATE: 8-6-18
Page 1 of 4
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
STATE OF FLORIDA - APPLICATION # AP1359965
DEPARTMENT OF HEALTH PERMIT # 56-SF-1870604
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATION ' DOCUMENT # SE1092019
APPLICANT: Joshua & Madison Revord
CONTRACTOR / AGENT: Karner Surveying, Inc
LOT: BLOCK:
SUBDxVISION: xD#:3229-211-0002-000-4
TO BE COMPLETED BY ENGINEER,. HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED. PERSON. ENGINEERS. MUST PROVIDE
REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 6.02 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 1
AUTHORIZED SEWAGE FLOW: 9029.99 GALLONS PER DAY [ 1500 GPD/ACRE OR 2500.GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 1000.00 SQFT UNOBSTRUCTED AREA REQUIRED: 750.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Site BM red capped IR in cutout CL of rd b
ELEVATION OF PROPOSED SYSTEM SITE 7.00 [ INCHES / FT ] [ ABOVE /
BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED
SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: 75 FT
DITCHES/SWALES: 75
FT NORMALLY WET: [ ]YES
[X]NO
WELLS: PUBLIC: FT LIMITED
USE: FT PRIVATE: 75FT NON -POTABLE:
FT
BUILDING FOUNDATIONS: 5 FT
PROPERTY LINES:
5 FT POTABLE WATER LINES:
50 FT
SITE SUBJECT TO FREQUENT FLOODING?
[ ]YES EX ]NO
10 YEAR FLOODING? [ ]YES
[X]NO]
10 YEAR FLOOD ELEVATION FOR SITE:
FT [ MSL / NGVD ]
SITE ELEVATION: FT [ MSL
/ NGVD
SOIL PROFILE INFORMATION 9TTR T
RnTT.
PPnFTT.R TNFnRMATTON STTF. 9
USDA SOIL SERIES:Riviera fine sand
Munsell #/Color Texture
Depth
1OYR 4/2
Sand
0 To 16
1 OYR 52
Sand
16 To 42
1 OYR 5/8
CMN/PRM RF
23 To 35
1 OYR 6/3
Loamy Sand
42 To 64
1 OYR 7/2
Sand
64 To 72
USDA SOIL SERIES:Riviera fine Sand
Munsell #/Color Texture
Depth
1 OYR 3/2
Sand
0 To 4
1 OYR 4/2
Sand
4 To 18
10YR 512
Sand
18 To 45
1 OYR 6/3
Sandy Loam
45 To 57
1 OYR 62
Sand
57 To 72
OBSERVED WATER TABLE: 45.00 INCHES [ ABOVE / BELOW]] EXISTING GRADE TYPE: [ PERCHED / APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION: 23 INCHES [ ABOVE / BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [X]YES [ ]NO DEPTH: 23.00 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: Sand/0.60 DEPTH OF EXCAVATION:
DRAINFIRLD CONFIGURATION: [ ] TRENCH [X] BED [ ] OTHER (SPECIFY)
r REMARKS/ADDITIONAL CRITERIA
VT determined using USDA WSS and soil borings.
1518 CMN PROM RF mottling In 1UYR5/2 matrix>2% starting at 23" in SB7.
7"below SM. S824"below _BM. _
SITE EVALUATED BY:
Ingram, Brian (TIP: Environmental Specialist II) (ENVIRONMENTAL HEALTH)
DR 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC
INCHES
DATE: 08/22/2018
Page 3 of 4
AP1369966 EID1870604 v 1.0.2