HomeMy WebLinkAboutSUBMITTED PAPPERWORKAp
County Health Deoartment
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
DIVISION OF HEALTH
Application and Pennit
of
Individual Sewage Disposal Facilities
Section I - Instructions:
1. Percolation test data, 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
recording of subdivision. If
not recorded, 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 461-5350 and give
this office a 24-hour notice
when ready for inspection.
Section II - Information:
1. Property Address (Street & House No.) Hawley Road
Lot Block Subdivision See Attached
Date Recorded Directions to Job-WeSt on Midway Roaa, ou on
Hawley Road- eet, lot on left _
2. Owner or Builder James SFrFawn, D.
P.O. Address 70 N._7th City Fort Pierce, Florida 33450
3. Specifications
Tank Drainfield
Gals. ft. of 6" clay tile
or 5" perforated
plastic drain in a .
Gov 3' trench or
Gals. -ft. of 4" clay drain
or 4" perforated„
plastic drain in an
8" trench
4. House to be constructed:
Check one: FHA
VA X Conventional
This is to certify that the project
descfibed in this application, and as
detailed by the plans and specifica-
tions and attachments will be con-
structed in accordance with state
requirements.
Applicant: James Strawn, D.D.S.
Please Print
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SCANKiD
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�St. Lucie C Ujpj)y
(Name of Street or State Road)
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Signature: lq q . a.. Date: April 11, 1977
QDO NOT + + + + + # + + + *WRITE BELOW THIS LINE + + + + + + + + + + + + + + +
Section III - Application Approval & Construction Authorization .
InstallatigFr subject„o/,€g,1k&ing special conditions:
The above signed application has been found to be in compliance with Chapter 17-13,
Florida A nistrative Co , and construction, -is hereby proved, subject to th'
above sfi a ions arj tions. �S
By: County Health Dept. Date
Section IV - F a1-Construction Approval .
Construction of installation approved: Yes No
Date: By:
FHA No'. VA No.
TEMPORARY
SAN 428
AEV, 7/1/73
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