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<br /> <br />STATE OF FLORIDA <br />DEPARTMENT OF HEALTH <br />ON-SITE SEWAGE DISPOSAL SYSTEM <br />APPLICATION FOR CONSTRUCTION PERMIT <br /> <br />PERMIT NO. <br />DATE PAID: <br />FEE PAID: <br />RECEIPT #: <br /> <br />;J<::>v (0 "200$" <br />'3S- J <br />P /6 'bq 7 <br /> <br />APPLICATION FOR: <br />[ ] New System <br />[ ] Repair [ ] Abandonment <br />APPLICANT: 7 -;Z.F-:J:=-A).} Y BA /?TovV FA)(-J 5~~ S~.,/l1 066J <br />AGENT: ,A1.:z:r::1-! A c:-L 5.1) 'r' DE f( TELEPHONE: 3>,..:7-,?...v-3'1~1 <br />MAILING ADDRESS: 110, /3of I ~33;:) 8/iOOksu,'1IQ", f"/ JSI(O Lf <br /> <br />[~Existing System <br /> <br />Holding Tank <br />Temporary <br /> <br />Innovative <br /> <br />---------------------------------------------- <br />---------------------------------------------- <br /> <br />TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED <br />BY A PERSON LICENSED PURSUANT TO 489.105(3) (m) OR 489.552, FLORIDA STATUTES. <br /> <br />= = = = = ~ == ;;.:"~ :: = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = <br /> <br />PROPERTY INFORMATION <br />BLOCK: SUBDIVISION: EfJ~tvoOIf) 5u13 Ab::t. PLATTED: <br /> <br />#: 1'( -2b -;;>/-0 ;??6 ~-~~~: I/M OR EQUIVALENT: <br /> <br />LOT: <br /> <br />PROPERTY ID <br /> <br />Y/N) <br /> <br />PROPERTY SIZE: <br /> <br />ACRES WATER SUPPLY: [ <br /> <br />] PRIVATE <br /> <br />PUBLIC [~=2000GPD [ <br /> <br />] >2000GPD <br /> <br />IS SEWER AVAILABLE AS PER 381.0065, FS? [Y / N ] DISTANCE TO SEWER: FT <br />PROPERTY ADDRESS: '9'6...?J cll.llRrel? ~r- <br />DIRECTIONS TO PROPERTY: hlcVY-;' ..30/ So 10 c AVE: WESt 7't) <br />cllAl?rER s-';- SOPTH, <br /> <br />BUILDING INFORMATION <br /> <br />] RESIDENTIAL <br /> <br />] COMMERCIAL <br /> <br />Unit <br />No <br /> <br />Type of l <br />Establishment <br /> <br />No. of Building Commercial/Institutional System Design <br />Bedrooms Area Sq Ft Table 1, Chapter 64E-6, FAC <br /> <br />1 <br /> <br />fifD8::aE ,I/o,)1c <br /> <br />'], ~B X 56 <br /> <br />2 <br /> <br />'" <br /> <br />k~?'cA( \NG f..' <br /> <br />PK-cJ,c-\,~ jI\II., If <br /> <br />3 <br /> <br />4 <br /> <br /> <br />DATE: <br /> <br />)1- A:) - 0...5 <br /> <br />DH 4015, 10/97 - Page 1 ( revious editions may be used) <br />Stock Number: 5744-001'-4015-1 <br /> <br />Page 1 of 3 <br />