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NO CARBON REQUIRED


APPLICATION FOR PERMIT Number ...........


SOUTHWEST FLORIDA WATER MANAGEMENT DISTRICT
P. O. Box 457, Brooksville, Florida 33512


1. Description of construction or use: .... ........... .. ....



2. Location:
County: Section:... 'Township: Range: ..............
B lock: .... L ot: ................... ...Subdivision :...............
3. "Works of the District" (Body of Water) involved (Section 16 CB-1 (1.03) ...... ..................


4. Name of applicant:................................ ......................
4 N am e o f ap p lica n t: ... ..... ....... ............. .... .. .......................................................,...........
Street or P. O B ox: .. .. .. .. .. ........ ........ ..... .
C ity .... ........................... State
5. Name of owner if other than applicant: .
Street or P. O Box.. .. .. .........:
City ............ .................. State .
If applicant is not the owner, a letter dated and signed by owner authorizing the applicant to act for him
must accompany this application.

6. Area (acre) proposed to be served: (If application is for drainage or irrigation connection, list the acre-
ages involved.) ... .. ...... ........

7. How soon after receipt of the permit will work commence? days. When will work be completed?
(If not completed by this date and no extension of time is applied for and granted, this
permit is voided.)
8. In the event that the requirements or interests of the Southwest Florida Water Management District indicate
that the removal or alteration of any structure or works installed by the permitted is necessary, or if the struc-
ture becomes in an unsafe condition, the structure or works must be removed or altered within 60 days of
notice and at no cost to the District. Should the pernmittee fail or refuse to alter, or remove the structure when
so notified, the SWFWMD may alter, repair or remove the structure or work and the costs incidental thereto
must be paid by the permitted.
9. Any erosion to or shoaling in a "Work of the District" caused by the permitted's construction shall be re-
moved or repaired promptly by the permitted at no expense to the District.
10. This application including sketches, drawing or plans and specifications attached contains a full and com-
plete description of the work proposed or use desired of the above described facilities of the District and
for which permit is herewith applied. It shall be a part of any permit that may be issued.

11. This application is subject to all stipulations which may appear on the approving transmittal letter.

Submitted this .. day of .. ... ....... 19

Signature of Applicant

(Initials) (Date)

Engineering D division Approved ..... .......... .....................
Maintenance Division Approved ....
Final Construction Com pleted .............. ..................
Applicant keeps Yellow Copy and sends White forward

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