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STATErOF: �FLORIDA PERMIT #
DEPARTME�jT��� O�F HEALTH
014SITE` SEWAGE; TREATMENT AND DISPOSAL SYSTEM
EXISTING,SYSTEM AND SYSTEM REPAIR EVALUATION
APPLICANT: 4405 Fort -Pierce LLC c/a Treasure Coast Contractors
CONTRACTOR K.R.K. Enterprises Inc c/o Kyle D. Kelly - Sit 093-1151
LOT: M&B BLOCK: N/A SUBDIV: N/A ID#: 2434-34.1-0001-0
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR
OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS;
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
EXISTING TANK INFORMATION
[ 3000
] GALLONS SEPTIC TANK LEGEND: unknown
MATERIAL; concrete
BAFFLED: [ N ]
(
]. GALLONS SEPTIC TANK LE.GEND :
MATERIAL:
BAFFLED: [ Y / N I
[
] GALLONS GREASE INTERCEPTOR LEGEND:
'TANK
MATERIAL:
MATERIAL:
# PUMPS:[1 L ]
[1000
] GALLONS DOSING LEGEND:
tap
I CERTIFY Fes. LISTED TANKS WERE PUMPED ON 16I M 21 _
BY JD w/ KRK.Enterprises, Inc. r
THE VOL S ' , ECIF'IE9 AS DETERMINED BY [ DIMENSIONS
1, ARE FREE OF OBSERVABLE
DEFEG
HA [ SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE ]
INSTALLED.
.: ,.
'- K.R.K. Enterprises- Inc
23 NOV 2021
SIGNATURE
of LICW D�CO,NTRACTOR BUSINESS NAME
DATE —
EXISTING DRAINFIELD INFORMATION
(I! ] SQUARE FEET PRIMARY DRAINF.IELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X-p
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
TYPE OF SYSTEM: [ ] STANDARD [ ] FILLED [ ✓f MOUND [ ✓ ] Dosed System w/ duplex panel
CONFIGURATION: [ ] TRENCH [ ✓r BED [ ]
DESIGN: [ ] HEADER [ ] D-BOX [ ] GRAVITY SYSTEM [✓] DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE 36" INCHES [BELOW ]
SYSTEM FAILURE AND REPAIR INFORMATION
[1989 ] SYSTEM INSTALLATION DATE TYPE OF WASTE [�/] DOISTX [ ] COMMERCIAL
[ �y�jv ] GPD ESTIMATED SEWAGE FLOW BASED ON [✓ ] METERED WATER [ ✓] TABLE 1, 64E=6', FAC
SITE
(
] DRAINAGE STRUCTURES
CONDITIONS:
[
]''SLOPING PROPERTY
I
NATURE OF
(
] HYDRAULIC OVERLOAD
FAILURE:
[
] DRAINAGE / RUN OFF
FAILURE
[
I
] SEWAGE ON GROUND
SYMPTOM.
[
] PLUMBING BACKUP
REMARKS/ADDITIONAL
CRITERIA,{1) MO a
SUBMITTED BY: 1Cy]e' ]). Kell`
DH 4015, 08/09 (obsolete
Incorporated 64E=6.001,.
[ ] POOL [, ] PATIO / DECK [ ] PARKING
[-w/ OC
[ ] SOILS [ ] MAINTENANCE [ ] SYSTEM DAMAGE
[ ] ROOTS [ ] WATER TABLE [ ✓ ] Unkmwn
( ] TANK [ ] D BOX/HEADER [ ] DRAINFIELD
[ ✓ ] Unimown
0 TITLE/LICENSE President / SR 093-115]DATE : 23NOV21
which may not be used)
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