HomeMy WebLinkAboutD.O.H. PAPPERWORKRECEIvG
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n STATE OF FLORID 1
DEPARTMENT OF H ALTHJAN 18 .,.i
o ONSITE SEWAGE T EAENT AND DISPOS L
SYSTEM �Yl Adel® 6gunty, Permitting
APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
[ ] New System [ ] Existing System [ ] Holding Tank
[ ] Repair ii[ ] Abandonment [ ) Temporary
APPLICANT: J'oro ah 1l/ o m m a A- o
��2$�l5
PERMIT NO. AN 0- 57
DATE PAID:
FEE PAID:
RECEIPT #:
[ ] Innovative
(1/ ] Plan Review
AGENT ;�C [/�Lg,ry %Cur �`/ %7 TELEPHONE: >=475
V
MAILING ADDRESS: _�Fj �A CoJ�.lye-1 nl Ave- O 4-11 l 3ei f'a 3
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. ^n1
lED
PROPERTY INFORMATION ,} BY
LOT: Z� BLOCK: (Q ¢ SUBDIVISION: l•L 71� �(/$lqi/QS PLATTED St• LUCID. GoUntV
PROPERTY ID #: �2-60/' OT�I�Wb'I ZONING:G� I/M ORfEQQUIVALENT: I Y/N0 ]
PROPERTY SIZE: / _ ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [ Pl<=2000GPD [ I>20fff0-00GPD
IS SEWER AVAILABLE AS PER 381.0065, PS? [ Y/b) 1 DISTANCE TO SEWER: FT
PROPERTY ADDRESS: � %� % �� �¢� �%� Q¢. i -G 'a- F—/
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [ ] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No, of Building Commercial/Institutional System Design
No Establishment Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
1 /C z-S/�¢r-feI .3 30 60 �10 /�.me��o•o q�q�e�C.
2
91
4
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE:
DATE-. j /
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC Page 1 of 4