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c STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
�•w�opWEIR�Authority: Chapter 381, FS & Chapter 1OD-6', FAC
CONSTRUCTION PERMIT FOR:
[ ,f New System [ ] Existing g System [ ] Holding Tank
[ ] Repair [ ) Abandonment [ ] Other(Specify)
II ti
APPLICANT: t=
PERMIT #
DATE PAID `
FEE PAID $ =
RECEIPT
[ ] Temporary/Experimental.
AGENT: Gu
\PROPERTY'STREET ADDRESS:
�1
OT: 1 BLOCK: SUBDIVISTON:
R9PER'rY ID #: we w �7 ' t
{, n'�•? [SECTION/TOWNSHIP/'RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER]
------------------------------------------
`STEA MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
�PAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
PIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
r
RFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A
S'IS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH
DZFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL, :AND VOID.
YSTEM DESIGN AND S''P��E,,CIFICATIONS
T [ <r j [C�ALLONSS/ GPD],'SEPTIC TAN AEROBIC UNIT CAPACITY MULTI-CHAMBERED%,_N SERIES:[ ]
A [ ] [GALLONS / GPD] CAPACITY MULTI=CHAMBERED/IN SERIES:[ ]
N [ J GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE -RATE [ ] PER 24 _HRS NO. OF PUMPS: [ ]
D [ SQUARE ,FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM �P 4 (,, _ '] STANDARD [ J 'FILLED [
I CONFIGURATION:k ' [ ] TRENCH [-,] BED
N
F LOCATION OF BENCHMARK: M
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM -OF DRAI:NFIELD TO BE[ 4
L
'D'"FILL REQUIRED:
0
] MOUND [ ]
c ;
i r
J [INCHES/FT] [ABOVE/BELOW] BENCHMARK/'REFERENCE POINT
] r [ INCHES/,'FT] (ABOVE/,,BELOW'],•*BENCHMARK/REFERENCE POINT
INCHES
EXCAVATION REQUIRED: j
r. ] INCHES
8 e -i
(4f1�
f d/ J old 4 3 •) !IF.
l�!
SPECIFICATIONSBY:
TITLE:
APPROVED BY: ti(
TITLE:
CPHU
ISSUED-
DATE:
o"i o �.
i
HRS-H Form 4016, Mar 92 (Obsoletes previous editions w`i ch mby not -be Used)
Page 1
of 2
(Stock Number: 5744 001 40U6 0)
' '
j • yytt
IN STRUCT X
IFF X, MIT IN U kfDrR'
trp.oking lulmba�v by CPHIJ,
APPLICXICION FOR,�
type tAperaut; if "otaZt" specii-YI-Yov n3blaluk-
APPLICAN'k;
property owner", full rzamt.
TELEPHONE:
1:01ephop ,o nurjbj-,r or zppNpw Or agent.
AGENT;
'evoperly owner's legally ftucfiof,zed upre4entative.
MAILING ADDRESS:
P.o, bQx or street nutiling addross for applic'ent OT agFut.
LOT, BLOCK, SILKHVISION OF or ID nu- (fpc roperty appmi�,or ID4 or
�nj�*r for - C
PROPERTY TDq: 27 ohsract yj -4,y� P111i may ioquire p
SYSTEM DESIGYN AND
SPECIFICATIONS:
TANK..
Minimum fruni Chapter FAA.
D RAI 13)
Mif-,iratIm frorg, Chapter IOD-6, FAC
OTHER-
soch aq operatirp p arrvil requitogla#113, lew.vohjmc swoh foileo, variance pr6yhos.
w3PECIFICATIONS BY;
APPROVE 0 B V:
County Pu,"Ixf--a�ah Wit (CPHV) ttvievwing and approviag perwit.
DAU iSSU-1W.
Dtc poim;t CPHU.
r�XPIRATION DATE
n^ati. yz-,r -Arom siiitt "t,-vc-d if 61� sya*m, has nO bcou� i"S1414*cd, pe"JL�-, fof sysAton rcp air becomic void 90 days fiom lbe
data i'sliu.0d.
°t
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD-6,
APPLICATION FOR:
P'7 PERMIT
r,+
r DATE PAID
FEE PAID
RECEIPT
FAC
New System [ ] Existing System [ ] Holding Tank'. [ ] Temporary/Experimental
[ ,] Repair. [ ]- Abandonment [ ] Other(Speeify).
APPLICANT: 4 TELEPHONE: aa
AGENT: r)
MAILING ADDRESS: d cad
�TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D-6, FLORIDA ADMINISTRATIVE CODE.
-----------=--=-------=-------------------------------------------------------------------------
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL -:'DESCRIPTION OR DEED]
LOT: 0' ! BLOCK: 3 SUBDIVISION: DATE OF
a z _00 � - 0 A SUBDIVISION:
PROPERTY ID: o [Section/Township/Range/Parcel No.] ZONING:
PROPERTY SIZE: e * ACRES [Sgft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [] PUBLIC
a
PROPERTY' . STREET "DRESS: o �^
DIRECTIONS TO PROPERTY: e la l C @ ,
BUILDING
INFORMATION
[ ] RESIDENTIAL [�
COMMERCIAL
Unit
Type of
No. of Building
#` Persons
Business Activity
No
Establishment
Bedrooms Area Sgft
Served
For Commercial Only
Vj
3
'4
.
[ ] Garbage Grinders%Disposals [ ] Spas/Hot Tubs [ ] Floor/Equipment Drains
[ l
Ultra oar+•Voume Flush Toilets [ ] Other (Specify)
.11 y Nee {�a
APPLICANT-S SIGN1411". DATE:
�''�' r }d" elf ;�• h, P `� i3 ,
DH 4015 ;10/96 (Replaces HRS-H,Form 4015 [Page 11 which may be used)
Page 1 of
(Stock Number 5744-001 4015-1)
INSTRUCTIONS:
APPLICATION FOR:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT, BLOCK,
SUBDIVISION;
DATE OF SUBDIVISION:
PROPERTY ID#:
Check type of permit, if "Other" specify type in blank.
Property owner's full name.
Telephone number for applicant or agent.
Property owner's legally authorized representative.
P.O. box or street, city, state and zip code mailing address for applicant or agent.
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot, +
legal description or deed must be attached.
Official date of subdivision recorded in county plat books (month/day/year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
27 character number for property. (Health' Department may require property appraiser ID# or section/township/range/parcel number.)
PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared roaJ
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be'included in calculating lot area. y
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table H, Chapter 1013-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants'.
BUILDING AREA: Total square footageofenclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
# PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2' persons per bedroom are
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table II, Chapter IOD-6, FAC. "
FDCTURES: Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE: Signature of applicant or agent. Date application on day submitted to Health Department with appropriate fees and attachments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and q.
other pertinent facilities or features on adjacent property, if the features are with'75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains, and fixture types, and other
features necessary to determine composition and quantity of wastewater.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE, SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
075
PERMIT ,f° f
APPLICANT: L ® A<-( YZ [ 5 T AGENT:
.LOT: ` BLOCK:. SUBDIVISION: kk i'vast. —X�py_
PROPERTY ID 4: 14zq -Sol- 00's'k 43co f No. or Tax ,ID Number
woe - 6C30a e� [Section/Township/Range/Parcel ]
-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.
PROPERTY SIZE CONFORMS TO SITE PLAN: [ YES ['] NO NET USABLE AREA AVAILABLE: O. o ACRES
TOTAL ESTIMATED SEWAGE FLOW: '° GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: 0 -ep'' GALLONS PER DAY [1500 GPD/ACRE OR 2500 G ACRE]
UNOBSTRUCTED AREA.AVAILABLE: 6:9- p0 SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK/REFEREN .E` P. NT LOCATION:
ELEVATION OF PRO'DASYSTEM SITE IS °',° [INCHESef7aOVE BELOW] BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES/SWALES: 1 g FT NORMALLY WET? [ ] YES `] NO
WELLS: PUBLIC: °_;gob FT LIMITED USE: !0 0 FT PRIVATE: ')`g FT NON -POTABLE: +9 0 FT
BUILDING FOUNDATIONS: .' FT PROPERTY LINES: '>5 FT POTABLE WATER LINES: 'Z ft� FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES DC] NO 10 YEAR FLOODING? [ ] YES [r�] NO
10 YEAR FLOOD ELEVATION FOR SITE: o+� FT MSL/N` GVi SITE ELEVATION: ?,0 FT MSLANGVD
y
SOIL PROFILE INFORMATION SITE 1
Munsell #/Color Texture Depth
to
to
to
to
to
t0
to
t0
t0
USDA SOIL SERIES:
SOIL PROF%LE INFORMATION SITE 2
Munsell &/Color Texture Depth
to
to
to
to
to
s to
to--.
0 : ,
'to
USDA SOIL SERIES:
^OBSERVED WATER TABLE: 41k INCHES [ABOVE /BELOW EXISTING GRADE. TYPE: [PERCHED /eAPPARENTA
ESTIMATED WET SEASON WATER TABLE ELEVATION:, INCHES [ ABOVE / E OW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES yS NO MOTTLING: [ ] YES 1194�1' NO DEPTH: INCHES
+SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: 34 INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [] BED [ ] OTHER (SPECIFY)
iEMARKS/ADDITIONAL CRITERIA:
.SITE EVALUATED BY
DH 4015, 10196 (Replaces HRS-H fi
(Stock Number: 5744-0034015-1)
which may be used)
r
of�3
INSTRUCTIONS:
PERMIT NUMBER:
APPLICANT:
AGENT:
LOT, BLOCK, SUBDIVISION:
Permit tracking number by County Health Department.
Property owner's full name.
Property owner's legally authorized representative.
Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section/township/range/parcel number). -
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non-residential), ,
Chapter 1 OD-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA: Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter IOD-6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS: Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE:
DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION:
ADDITIONAL CRITERIA:
SITE EVALUATED BY:
Record soil texture or loading rate for system sizing.
If applicable record depth of excavation required. Record "NA" if not applicable.
Check drainfield configuration required. If other, specify type.
Record any, additional remarks pertinent to site or installation. Ex. dosing required.
Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.',
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. [ - ] SHOT [ - ] SHOT (- ] SHOT
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