HomeMy WebLinkAboutSewage PermitSTATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority; Chapter 381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
[ ,J New System [ ] Existing System
[ ] Repair [ ] Abandonment
AMLICANT'•
PROPERTY STREET ADDRESS:
PERMIT #
DATE PAID _�-
FEE PAID $
RECEIPT #
] Holding Tank [ ] Temporary/Experimental
[ ] Other(Specify)
AGENT:
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 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
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID..
SYSTEM DESIGN AND SPECIFICATIONS
T [�] a[GTLLONS)/ GPD] SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED/IN SERIES:[ ]
A [ ° ] ['GALLONS / GPD], CAPACITY ;MvLfiI-CHAMBE_RED/IN'SERIES: [ ]
N[ ] GALLONS GREASE INTERCEPTOR_CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
R [ �_ ] GALLONS PER DOSE 'DOSING TANK CAPACITY- DOSE RATE [,/] PER 24 HRS NO. OF PUMPS: [,]
D [ 6, ]`SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ J MOUND [ ]
I CONFIGURATION:F i'' TRENCH BED
(.a
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [INCHES/FT] {ABOVE/BELOW] BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ) [�INCHE:/FT] �[ABOVFr/BELOW]-BENCHMARKREFERENCE POINT
L
D FILL REQUIRED: [ ] INCHEyS EXCAVATe^ION REQUIRED: [ ] INCHES
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SPECIFICATIONS BY: TITLE:
r1 APPROVED BY:-
TITLE: " r
� � CPHU
DATE ISSUED• / m EXPIRATION DATE
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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.
a
VN
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)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
Minimum specifications from Chapter 1013-6, FAC.
DRAINFIELD:
Minimum specifications from Chapter IOD-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. `