1841 Ocean Grove Drive WELL-SEPTIC CONVERSION App 07.05.2006 j _,J-\i`./:/- CITY OF ATLANTIC BEACH
JS J S' BUILDING AND PLANNING
\s 800 SEMINOLE ROAD
ATLANTIC BEACH,FLORIDA 32233-5445
t , ' Q ..;_ ' j TELEPHONE:(904)247-5800
c6 FAX:(904)247-5845
http://ci.atlantic-beach.fl.us
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July 5, 2006
Kristin Lynn Smith
1841 Ocean Grove Drive
Atlantic Beach, Florida 32233
Re: 1841 Ocean Grove Drive—Septic to sewer conversion
Dear Ms. Smith:
The City of Atlantic Beach has received you application for fmancial assistance to connect to
City sewer, however, your income exceeds that which is eligible to receive Community
Development Block Grant (CDBG) funds to pay the cost to convert your septic system to City
sewer. The City's use of these grant funds for individual households is limited to those
homeowners who meet the low and moderate income limits as established by the federal HUD
Section 8 program. The City has no discretion to use these funds unless all eligibility
requirements are met, and we are audited yearly to verify proper use of funds.
Please feel free to contact me at 247-5826 or sdoerr@coab.us with any further questions you
may have.
Sincerely, a
Sonya B. Doerr,AICP
Community Development Director ,.
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City of Atlantic Beach - 800 Seminole Road -Atlantic Beach,Florida 32233-5445
Phone: (904)247-5800 • FAX (904)247-5805 • http://www/ciatbntic-beach.fl.us
APPLICATION FOR ASSISTANCE
WITH CONVERSION FROM SEPTIC TANK TO CITY SEWER
2004-2005 COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM
The information requested on this form is required in order to determine your eligibility to participate in this
program. (These funds may be available to homeowners whose incomes are within low and moderate levels
based upon family size and as established by HUD Section 8 Income Limits.) Please answer all questions,
and provide copies of all required documents. (Your information is considered confidential.) Funds for this
program area available only for single-family residential houses and for homeowners who live in their
home. (Homes cannot be rental houses.) Grant funds are limited, and applicants are selected based upon
most urgent and serious need and availability of funds.
DATE: ( 9 2' /0(r
1. Homeowner Name(s): A Y\ L ()i' T (i
Thh
2. Address of Home: \ct-4 I OCCJ (�iftv\e- .6(Q1 • ' 3a-33
3. Telephone Number: ZLI I I DZ— (day) L{ 1 2- - C D7 3 (night)
4. Is the person completing this application the Head of Household? )yes ❑no 0 female 0 male
5. How many family members live in this house? 4
6. Are there people living in this house with disabilities or special needs? 0 yes , no If yes, please
explain
7. Number and age of persons living in the household in addition to Head of Household.
Ages 0—5 years old Male Female
Ages 6—17 years old - Male Female
Ages 18—39 years old Male I Female
Ages 40—64 years old Male Female
Ages 65 and older Male Female
8. Water supply is provided by: (City Water ❑ Private Well Other
9. Does septic system work properly? Yes❑No If no,please explain.
Page 1of3
10. Does your plumbing work properly? Yes 0 No
If no,please explain.
11. Is there hot and cold running water in your house? )Yes ❑ No
12. Do you have a complete kitchen with running water,a refrigerator and cooking facilities? td-e_9
13. How many persons are in your family and living at this address? <
14. Federal regulations require that we keep track of certain demographic information and the type of
households being served. Please check the appropriate box below.
White,Not Hispanic
O African-American,Not Hispanic
El American Indian or Native Alaskan
❑ Hispanic
O Asian or Pacific Islander
Female Head of Household
❑ Other /, ,,�
15. What is the total annual income(before taxes)of your household? (/5� OC D
16. Are you on a fixed income such as Social Security,SSI or retirement? 0 Yes 'No
17. What are your sources of income? �Vl pi
18. Do you own this home? Z Yes 0 No
If you own your home, please provide a copy of your deed and a recent water or electric bill which shows that
you live at this address. If you rent your home, please provide a copy of the lease.
16 1L .
Signature of Owner Date
If you have any questions about this application or need any assistance preparing
the application, please contact the City of Atlantic Beach at (904) 247-5826.
The attached Income Verification Form must also be completed and mailed to:
Community Development Department
City of Atlantic Beach
•K/`it . 800 Seminole Road
Atlantic Beach, Florida 32233
In order to arrange to inspect your home for needed repairs, please provide the time of day and
day of the week (Monday through Friday) when it would be most convenient to make
arrangements for a Building Inspector to meet with you, and the phone number where you wish
to be called.
Page 2 of 3
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INCOME VERIFICATION FORM
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PART I. (To be filled out by the person (employee)completing this application.)
Applicant/ Employee name: tApti/
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Address: g 1 0 eetto( Y 1
Social Security Number: O Lt 7(9—
I hereby authorize release of my income information to the City of Atlantic Beach for
the purpose of applying for participation in the Housing Rehabilitation Assistance
Program, which is funded by a Community Development Block Grant.
i SANILv\ 24CI ISP
Sign re Owner Date
PART II. (To be filled out by employer,Social Security Administration or HRS.)
Please provide the following information and return to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach,Florida 32233 p�
Applicant/Employees Name: ' 04)r' v cV'��l.C1'
Gross Monthly Income: $
Is employment: ISZI permanent ❑ part-time ❑ temporary
Employer Name: fJjr) CL,cr,t
CSCD -{ C
Address: alb Sblui
Rd . -ic fL 52Telephone: -261p-6490
Name and title of person providing this information. Date
Page 3 of 3
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