HomeMy WebLinkAboutSewageSTATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE 'SEWAGE DISPOSAL SYSTEM.
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D-6k FAC
0
PERMIT #
DATE PAID A2/-.' i
FEE PAID
RECEIPT #
CONSTRUCTION PERMIT FOR:
[X ] New System [ ] Existing System [ ] Holding Tank' [ ] Temporary/Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT: F2`2 r AGENT:
`�� �Ma� r�;t�ia1'i�' ��'°��E �y��_,r'f.-"rse;� t't NR r?s•;�4'dt`�„ i+'.'L.,
.v t CYe�s .3'v+�.,d. i s -
PROPERTY STREET ADDRESS:
LOT/2 LOT "° ��.$I;OCK:� "a� n SUBDIVISION:
PROPERTY ID #": r .[SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST.BE''CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6; FAC
REPAIR PERMITS AND HOLDING TANK•PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
'EXPIRE ONE-YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH
MODIFICATIONSMAY RESULT IN•THIS PERMIT BEING MADE NULL AND VOID.
---------------------
SYSTEM DESIGN.AND SPECIFICATIONS
T (
] [GALLONS
/ G$D] SEPTIC TANK/AEROBIC UNIT
CAPACITY MULTI-CHAMBERED/IN SERIES:[ ]
A [
],[GALLONS,/
GPD]
CAPACITY MULTI-CHAMBERED/IN SERIES:[ ]
N [
] GALLONS''
GREASE `INTER69PTOR CAPACITY
[,MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ =7)
J GALLONS
PER. DOSE -.DOSING TANK -CAPACITY
DOSE RATE PER 24 HRS NO. OF PUMPS: [ ]
D
R
-•A
I
N
..F
I
E
' L
D
0
T
H
E
�R
SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ f ] SQUARE FEET. Ma�SJ +;7s�:'.4 S°Y'STEM Ga;'G
TYPE SYSTEM: [ ] STANDARD ( J FILLED
CONFIGURATION: U q(p � [, ] "TRENCH [ X ] BED
LOCATION OF BENCHMARK•:,;
[ '.; ] MOUND
ELEVATION OF PROPOSED SYSTEM SITE [ ] (INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE ( ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
FILL REQUIRED:-[ 0`3 ] INCHES
F
EXCAVATION REQUIRED: [ �] INCHES
j py j 74
SPECIFICATIONS BY N,,!>" ,' `" TITLE:
APPROVED BY: ¢ } TITLE:
DATE ISSUED:
•`
9i 01 A/!1-A�
4� d2ly� F,
�-%
a t`9 6v`,r •? ta•.�f �
I {, CPHU
ate)
EXPIRATION DATE: •n®
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5.744-001-4016-0)
BUILDING DEPARTMENT
Page 1 of 2
INSTRUCTIONS:
n
PERMIT NUMBER:
Permit tracking number assigned by CPHU. y '
"OF
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 11) # or section/township/range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
Minimum specifications from Chapter 1013-6, FAC.
DRAINFIELD:
Minimum specifications from Chapter 1013-6, 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 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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