HomeMy WebLinkAboutSewage ApprovalAPPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
"I 1. �. 1 //) AGENT:
PROPERTY STREET ADDRESS:
rr,nMIT #
RECEIPT #
FEE PAID
DATE PAID
LOT: / BLOCK: . f /j� SUBDIVISION: �� J%`�VV Yp d /fAR-P,
li�/-6 I� l ��J/
PROPERTY ID #: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER]
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CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 10D-6, FLORIDA ADMINISTRATIVE CODE.
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TANK INSTALLATION SETBACKS
[ ] [01] TANK SIZE [1] �2] JJJ �[ ] [27] SURFACE WATER
[ ] [02] TANK MATERIAL [28] DITCHES
03 OUTLET DEVICE "' """ [ ] [ ] ^�� z� '�' [ �...]?, [29] PRIVATE WELLS
[ ] [04] MULTI-C.3'-� PU LAIC WELLS
[ ] [ 05 ] LEGEND ] TI WELLS
[ ] [06] WATERTIGHT [ ][ ]ABL�7ATER LINES
[ ] [07] LEVEL [ ] [3 ] BFJILDI,,G FOUNDATION
[ ] [ 08 ] DEPTH OF LID [ 34 ] PROPERTY LINES
[ 35 ] OTHER
DRAINFIELD INSTALLATION ^ %�•
[09 ] ARE [ 2 ] ' ILJ, � SQFT
[10 IS
BtX/HEADER
[11] NES
[12] DRAINLINE SEPARATION
[13] DRAINLINE SLOPE ll
[14] DEPTH OF COVER
[15] SYSTEM ELEVATION
[16] SYSTEM LOCATION
[17] DOSING PUMPS r�
[18] AGGREGATE SIZE
[19] AGGREGATE SOURCE
[20] AGGREGATE WASHED
[21] AGGREGATE DEPTH
FILL/EXCAVATION MATERIAL
[ J [22] FILL AMOUNT
[ ] [23] FILL TEXTURE
[ ] [24] EXCAVATION DEPTH
[ ] [25] EXCAVATION AREA
[ ] [26] REPLACEMENT MATERIAL
CONSTRUCTION [ PROVE /DISAPPROVED]:
FINAL SYSTEM [APPROV /DISAPPROVED]:
DH 4016, 9196 (Replaces HRS-H Form 4016 [page 2] which mayC used)
(Stock Number: 5744-002-4016-4)
FILLED/MOUND SYSTEM
[ ] [36] DRAINFIELD COVER
[ ] [37] SHOULDERS
[ ] [38] SLOPES
[ ] [39] STABILIZATION MATERIAL
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT.
[44] BUILDING AREA
[45] PLUMBING FIXTURES
[46] FINAL SITE GRADING
[47] CONTRACTOR
[48] OTHER --
ABANDONMENT
[ ] [49] TANK PUMPED
[ ] [50] TANK CRUSHED AND FILLED
DATE: J
DATE: /
Page 2 of 2
APPI Il^-AKIT
Permit tracking number assigned b� . 1D.. .
Property owner's'full name.
Property .owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT,, BLOCK, SUBDIVISION Lot, Block and Subdivision for lot or
PROPERTY ID#: = 27,character number for property. (property appraiser ID #or GIS location),
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH•CONSTRUCTION PERMIT AND --
STATUTE OR'RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model):
LEGEND (manufacturer code) .
DRAINFIELD AREA (square feet) .
DISTRIBUTION BOX /.HEADER (check box) -
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM) -
.DOSING PUMPS (number. installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system) --
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS:, Record item number, explanation of violation, and required
CONSTRUCTION APPROVAL: Circle approved or. disapproved, CHID signature and date.
FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval.
Final.approval shall not be.granted unit the CHD has confirmed that building construction and lot grading are insubstantial -
compliance with'plans.and specifications -submitted with the -permit application.
ELEVATION 1NORKSHEET ELEVATION OF BENCHMARK OR REFERENCE. POINT: "` r
EXISTING GROUND TOP OF AGGREGATE
[+] SHOT H.I. H.I. H.I.
SHOT H SHOT,' ' [-] SHOT
ELEVATION _ - _