HomeMy WebLinkAboutConstruction Permit SewageSTATE OF FLORIDA PERMIT # -
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE,PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
[;r] New System [ ]' Existing System [ ] Holding Tank [ ] Temporary/Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT: "
PROPERTY STREET ADDRESS:
AGENT:
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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 [4, t�-a j [GALLONS / GPD] 'SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED%IN SERIES:c[.-]
A (' ] (GALLONS / GPD) CAPACITY MULTI-CHAMBERED/IN SERIES:[ ]
N [' ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ J GALLONS PER DOSE -.DOSING TANK CAPACITY DOSE -RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [(r ] SQUARE FEET f?RIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET - - SYSTEM
A TYPE' SYSTEM: ( ] STANDARD [ ] FILLED [ '']y14OUND [ ]
I CONFIGURATION: [` ] TRENCH [ ] BED
N t,
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ r ] INCHES./FT] [A$®VE/BELOWj'BENCHMARK/REFERENCE POINT
E'tBOTTOM OF DRAINFI'ELD TO BE [ ]•'[INCHES/FT]`(ABOVE /BELOW] BENCHMARK]/REFERENCE POINT
D FI'LL REQUIRED: [ '' J I'NCHES EXCAVATION REQUIRED: [ ," ] INCHES
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SPECIFICATIONS BY: TITLE:
APPROVED BY:
DATE' ISSUED: ' x
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TITLE': I-' '
+ f `CPHU
EXPIRATION DATE
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0)
BUILDING DEPARTMENT
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number 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.
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 IOD-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.