HomeMy WebLinkAboutSewageSTATE OF FLORIDA
DEPARTMENT OF HEALTH =*1REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
[] New System [ ] Existing System- [ ] Holding Tank
( ] Repair [ ] Abandonment [ ] Other(Specify)
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PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ ] Temporary/Experimental
APPLICANT
AGENT:
PROPERTY STREET ADDRESS
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"LOT:��I 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 90 DAYS -FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
PERFORMANCE FOR ANY SPECIFIIC PERIOD OF TIME. ANY CHANGE IN MATERIAI 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.. IF AREA OF DRAINFIELD IS SUBJECT TO
SYSTEM DESIGN AND SPECIFICATIONS ROOF MUST BE GUTTERED PRIOR TO ,
FINAL APPROVAL.
T [ }`] [GALLONS / GPD] SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED�IN 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 CDOSIN6 TANK CAPACITY-) DOSE RATE [] PER 24 HRS NO. OF PUMPS: [aJ
D [„} ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM [ ] STANDARD [ ] FILLED [] MOUND [ ]
I CONFIGURATION: " w .; [ ] TRENCH [_ ], BED
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ � ] {+INCHES/FT.j--[ABOVE-/-BEI O:W]-=BENCHMARK/REFERENCE---POINT
E BOTTOM OF DRAINFIELD TO BE ( _ �t �.` ,� j,-INCHES/FT,]-_.[.ABOVE%BELOW]- BEN.CHMARK/R-EFERENCE:-,I?OIN
L
D FILL REQUIRED:, ['i ] INCHES EXCAVATION REQUIRED [`fy-] INCHES
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SPECIFICATIONS tBY.:
APPROVED BY: �?
DATE ISSUED:
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.„�+'ip"-• � .. •'_5 .`tq'fv$ �`, 'TITLE':` '�..�;'�; rp Via• .s�k{lr �'. - ~e{`.....� s- t.... `�;T V�ih; 'i i �`sf` r.'.ei
TITLE: ° CPHU
EXPIRATION DATE
HRS-H Form 4016, Mar 92 (ObsoGetes previous editions which may not be used)
(Stock Number: 5744-001-4016-0)
BUILDING DEPARTMENT
Page 1 of 2,
INSTRU6arlONS: r
y
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PERMIT NUMBER:
Permit tracking number assigned by CPHU".
141
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 N or section/township/rangelparcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK;
Minimum specifications from Chapter IOD-6, FAC.
DRAINFIELD:
Minimum specifications from Chapter IOD-6, FAC'.
OTHER:
Othcr 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 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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