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STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
{:{7 New System [ ] Existing System [ j Holding Tank [ ] Temporary/Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT• - AGENT:
PROPERTY STREET ADDRESS;
LOT: BLOCK: SUBDIVISION:
h - -
tPROPERTY ID #: e - [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER]
________________ _________________________________________________________________________
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOE'S NOT GUARANTEE SATISFACTORY
"-!PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND 'SPECIFICATIONS
T[ ] [GALLONS / GPD] SEPTIC TANK/AEROBIC UNIT CAPACITY -'MULTI-CHAMBERED/IN SERIES:[ J
A [ ] [GALLONS- / GFD] t }�:.- '` `r,� CAPACITY MULTY=CHAMBERED/IN SERIES:[ ]
" N [ ] GALL -OW` GREASE INTE EPTOR CAPACITY (MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS)
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ `] PER 24 HRS NO. OF PUMPS: [`]`
D [ r:� i,.r ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: STANDARD [ ] FILLED [ _ ] MOUND [ ] Fft °•' '
I CONFIGURATION: Ca, [ ] TRENCH BED
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LOCATION OF BENCHMARK: a' -
ELEVATION OF PROPOSED SYSTEM SITE~[ ] .[INCHES/FT]-_-[_ABOUEa>BELOW.].-BEACHMARK/REFERENCE. POdNT
BOTTOM OF DRAINFIELD TO BE NCiiE'15./__F.,T_]_J.ABOVE/-BELO.W.]--BENCHMARK/REFEREN.CE-POINT,
FILL REQUIRED: [`t>'� ) INCHES EXCAVATION REQUIRED: [ ] INCHES
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SPECIFICATIONS-,
TITLE:
APPROVED
TITLE:y
CPHU
DATE ISSUED:
r
.EXPIRATION DATE:
I
HRS-H Form 4016, Mar 92 (obsoletes previous editions which may not be used). Page 1 of 2
(Stock Number: 5744-001-4016-0)
BUILDING DEPARTMENT
INSTRUCTIONS:
PERMIT NUMBER:
Permit tracking number assigned by CPHU.
APPLICATION FOR:
Check type of permit, if "Other" specify type in blank.
APPLICANT:
Property owner's full name. *'
TELEPHONE:
Telephone number for applicant or agent.
AGENT:
Property owner's legally authorized representative. "
MAILING ADDRESS:
P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#:
27 character id number for property. (CPHU may require property appraiser ID # or section/township/range/parcel number)
l
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
Minimum specifications from Chapter 1013-6, FAC.
1.
DRAINFIELD:
Minimum specifications from Chapter 1013-6, FAC. r
{t
OTHER:
i
Other specifications, such as operating permit requirements, Tow -volume flush toilets, variance provisos.
SPECIFICATIONS BY:
Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY:
County Public Health Unit (CPHU) personnel reviewing And approving permit.
DATE ISSUED:
Date permit is issued by CPHU.
EXPIRATION DATE:
One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the date
issued.
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STATE OF' FLOR--FDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SXSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
APPLICATION FOR:
[t,4 New System ( ] Existing System [ ] Holding Tank
[ ] Repair [ ] Abandonment n[ ] Other(Specify)
APPLICANT: K;d'S oCf -14h 'PnCG
AGENT : M (^ p 1' r fe
,NS-�C' U C l to a\3
PERMIT ,#
DATE PAID
FEE PAID $
RECEIPT #
( ) Temporary/Experimental
TELEPHONE:
N fro 1 f�
MAILING ADDRESS: IDZ TOO) 4 ) i � 1 ) ci
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
•; rip.-5 = ��cn.ur d.� �P�Uz-�p'�.c•�-3-�-cl1.l:.�t.vZv�;�.
LOT: !� BLOCK: SUBDIVISION: )phi i� ,J , IDATE OF I a- 1
SUBDIVISION.
PROPERTY ID #: %(���f�1_! In��J [Section/Township/Range/Parcel No. ] ZONING:t _mM
PROPERTY SIZE: fD° 1 q ACRES [Sgftt/`f43556600] PROPERTY WATER SUPPLY: [ ] PRIVATE [�L)(/t PUBLIC
PROPERTY STREET ADDRESS:
•DIRECTIONS TO PROPERTY:
r- < v , - }C
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BUILDING INFORMATION [ ] RESIDENTIAL [ COMMERCIAL
Unit Type of No. of Building # Persons
No Establishment Bedrooms Area Sgft Served
PA
34
Business Activity
For -Commercial Only
['Garbage Grinders/Disposals [---'j`Spas/Hot Tubs [Floor/Equipment Drains
Ultra -low Volume Flush Toilets [__.-Other (Specify)
RAPPLI CANT ' S SIGNATURE: DATE:
�L v I� �"� � ��- v ,
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HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) Page( 1-'df' -
(Stock Number: 5744-001-4015-1)
PROPERTY ID #: FI(-f i��-(�(�-'� %Ci[Section/Township/Range/Parcel No. or Tax ID- Number]
-------------------------
TO BE COMPLETED BY ENGINEER, HEALTH. UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST.
PROVIDE REGISTRATION:NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL.ITEMS.
7_____
RROPERTY SIZE CONFORMS TO SITE P [�] YES [ ] NO NET USABLE AREA AVAILABLE: rs 7�� ACRES
TOTAL ESTIMATED SEWAGE FLOW: GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
17lUTHORIZED SEWAGE FLOW: OM GALLONS PER DAY (1500 GPD/ACRE OR 2509^G I1/ACRE]
UNOBSTRUCTED AREA AVAILABLE: LamO SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK/REFERENCE •POINT LOCATION: C! 0r f4 L-1 (7� ce '(''er 0 er5g
jELEVATION OF PROPOSED SYSTEM SITE IS INCH , ] [ABOVE ELOW BENCM4 yitEFERENCE POINT
THE MINIMUM.SETBIICH CAN BE MAINTAINED FROM-TIIE PROPOSED SYSTEM TO�THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES SWALES: FT NORMALLY WET? [ j YES �[�O
WELLS: PUBLIC: FT, MITED USE: FT PR7 TE: 2 FT NON -POTABLE: , FT
BUILDING FOUNDATIONS: FT, PROPERTY LINES: 1 FT 'POTABLE WATER LINES: //5 FT
SITE SUBJECT TO.FREQUENT FLOODING:_ [ ] YES [61""NO 10 YEAR FLOODING? [ ] YES [] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
HOIL PROFILE INFORMATION SITE 1
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USDA SOIL SERIES:
SOIL PROFILE INFORMATION SITE 2
Munsell #/Color Texture Depth
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USDA SOIL SERIES:,
OBSERVED WATER TABLE: jCHDELl,.[ABOVE. / LOWA EXISTING GRADE. TYPE: ERCHED ESTIMATED WET SEASON WATER TABEVATION: I CHE [ ABOVE / .] EXISTIN
i�i
SIGH WATER TABLE VEGETATION: [ ] YES �'['�j NO MOTTLING YES [lj"'NO DEPTH: INCHES
-OIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: .C� " DEPTH OF EXCAVATION: ' 7 _ INCHES'
DRAINFIELD CONFIGURATION: [ ] TRENCH [ BED,-, [ ] OTHF�R ( ECIF
RE/MARKS/ADDITIONAL CRITERIA:
r_/_rE�J
SITE EVALUATED BY: DATE: ' E `
HRS-H Form:4015, Mar 92 (Obsoletes previous edilti s''uhiclh iiia `bt k used) Page-3 of 3
(Stock Number. 5744-003-4015-1)