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STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
,CONSTRUCTION PERMIT FOR:
PERMIT #
DATE PAID
FEE PAID
RECEIPT
[" J New System [ ] Existing System [ ] Holding Tank [ J Temporary/Experimental
[ ] Repair [ ]' Abandonment [ ] Other(Specify)
APPLICANT: AGENT: --5 b _
PROPERTY STREET ADDRESS: '
LOT: BLOCK: SUBDIVISION: '
PROPERTY ID #: [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 9.0 DAYS FROM THE DATE OF ISSUE. ALL OTHER
PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. DEPARTMENT OF HEALTH APPROVAL OF SYSTEM DOES
NOT GUARANTEE 'SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL
FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THI°S 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:[ ]
A [ ] [GALLONS / GPD] CAPACITY MULTI-CHAMBERED/IN SERIES:[ ]
N ( ] 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: [ J
D [ ] SQUARE FEET PRIMARY DRAINFIEL'D SYSTEM ,c
R [ J SQUARE FEET SYSTEM
A 'TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ],
I CONFIGURATION: [ ] TRENCH [ ] BED
N ,r
F� LOCATI'ON OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [,"t ] [INCHES/FT] JABOVE/BELOW] BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED': [ ] INCHES EXCAVATION REQUIRED: [' ] INCHES
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: ;
DH 4016, 10/96 (Replaces HRS-H Form 401.6 [page 11which may be used)
(Stock Number: 5744-001-401")
TITLE:
TITLE:
CHD
EXPIRATION DATE:
Page I of 2
Building Department
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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. (Health Department may require property appraiser ID# or *,
section/township/range/parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1013-6, FAC.
DRAINFIELD: Minimum, specifications from Chapter LOD-6, FAC.
OTHER: Other specifications, such as operating permit requirements, low -volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
MICHAEL A. LUE, P.E.
mi
�1 Consulting Engineer
116-43rd Ave. SW
Vero Beach, Florida .32968
(561) 569-1257
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JOB NAME MA\,/ERICK 130AT5
LOCATION 5T. LUGIE COUNTY, FLORIDA
JOB NO. as-I6I SHEET NO. 5KI OF 1
DRAWN BY: ML ` DATE: 1/20/00
SUBJECT: R15ER SCALE: A5 NOTED
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AL PENETRATIONS THROUGH SECOND FLOOR DECK SHALL HAVE A (1) HR RATING