HomeMy WebLinkAbout96050272 - APPLICATION FOR CONSTRUCTION PERMIT.COD WE
APPLICATION FOR:
[ X ] New System
[ ] Repair
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE,SEWAGE DISPOSAL SYSTEM FEE PAID $ Imo®
APPLICATION FOR CONSTRUCTION PERMIT RECEIPT # ✓O�,�i�
Authority:.,.Chapter 381, FS�& Chapter 1OD-6, FAC
[ ] Existing System [ ] Holding Tank [ ] Temporary/Experimental
[ ] Abandonment [ ] Other(Specify)
APPLICANT: CURTIS WILSON
TELEPHONE: 461-0784
AGENT: PORT ST. LUCIE PROPERTIES/AYLOR, INC.
MAILING ADDRESS:
1712 Gulfstream Ave., Ft. PIerce. Florida 34949 -
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TO BE COMPLETED BY APPLICANT OR APPLICANT'SAUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
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PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: SUBDIVISION: DATE OF
2 25 Lakewood Park #4 6-13-57
SUBDIVISION:
PROPERTY ID #: [Section/Township/Range/Parcel No.] ZONING:
PROPERTY SIZE:9,825 ACRES [Sgft/43560] PROPERTY WATER SUPPLY: [X ] PRIVATE [ ] PUBLIC
PROPERTY STREET ADDRESS:
Eden R Rd.. Ft. Plerce. Florida
DIRECTIONS TO PROPERTY:
See attached site maA
BUILDING INFORMATION [ X] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Saft Served For Commercial Only
.1
1 Story residence 3 1247 4
2
.3
4
[ 1] Garbage Grinders/Disposals [ 0] Spas/Hot Tubs [0 ] Floor/Equipment Drains
[ 0] Ultra -low Volume Flush Toilets [ 0] Other (Specify)
APPLICANT IS SIGNATURE PL DATE: 4®12-96
U
HRS-H Form 4015, Mar 92 (obsoletes previous editions which may not be used) Page 1 of 3
(Stock Humber: 5744-001-4015-1)
INSTRUCTIONS:
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, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK, Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot
SUBDIVISION: legal description or deed must be attached.
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month/day/year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
PROPERTY ID#1: 27 character number for property. (CPHU may require property appraiser ID ## or section/township/range/parcel number.
PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter IOD-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
N.PERSONS:
Number of persons residing, using, or working in establishment, For residential establishment, 2 persons per bedroom are
assumed.
BUSINESS ACTIVITY:
For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table II, Chapter 1013-6, FAC.
FIXTURES:
Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE:
Signature of applicant or agent. Date application one day submitted to the CPHU with appropriate fees and attachments.
ATTACHMENTS:
A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of wastewater. .
IJO& O ' Wi 150
STATE OF FLORIDA PERMIT #
- DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID e/3
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ rl.9�0 --
CONSTRUCTION PERMIT RECEIPT # U t 1-3
Authority: Chapter 381, FS & Chapter 1OD-6, FAC X .yp-
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [
[] Repair , -[ ] Abandonment [
APPLICANT: Cu a-, U�) (I c
PROPERTY STREET ADDRESS:
LOT: BLOCK: t" SUBBsDIVISI/OON:,
Holding Tank
Other(Specify)
[ ] Temporary/Experimental
AGENT: pg(
n V
r,
�lsi J CSZJ /��1 lei 1A �&
PROPERTY ID #: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
(OR TAX ID NUMBER] u
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 [ ] jC4 ON / GPD]�SEPTIC TANKPAE OBIC UNIT CAPACITY TI-CHAMBERED/I' SERIES: (
A [ ] `[-GALLONS / GPD] `^-- CAPACITY -MUM—GH•AMBE1T D/IN SERIES: [ ]
N { ] GALLONS- GREASE INTERCEPTOR CAPACITY [MAXIMUM'CAPACITY'SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D
R
A
I
N
F
I
E
b
D
b
T
H
E
R
[°V _?] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD .[ ] FILLED
CONFIGURATION: [ ] TRENCH [9s] BED
LOCATION OF BENCHMARK: C/7� LOY9 / C
ELEVATION OF PROPOSED SYSTEM S4ITE [ 6 0
BOTTOM OF DRAINFIELD TO BE [ ] ![
[&4] MOUND [ ]
] [ABOVE
FILL REQUIRED: [Lt(i-j] INCHES EXCAVATION REQUIRED:
[ / ] INCHES
- _ e
POINT
POINT
SPECIFICATIONS BY: TITLE:
APPROVED BY: r J TITLE:. CRHU
DATE ISSUED: `� / EXPIRATION DATE:
IF AREA OF DRAINFIELD IS SUBJECT TO l
SATURATION FROM ROOF DRAINAGE,
HRS-H Form 4016, Mar 92 (obsoletes previous editions which may not be used) ROOF MUST BE GUTTERED PRIOR TO Page 1 of 2
(Stock Number: 5744-001-4016-0) 1 FINAL APPROVAL.
APPLICANT
INSTRUCTIONS:
p-
PERMIT NUMBER:
Permit tracking number assigned by CPHU.
s- .
APPLICATION FOR:
M
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 IDN:
27 character id number for property. (CPHU may require property appraiser ID k or section/township/range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: -
Minimum specifications from Chapter 1013-6, FAC.
DRAINFIELD:
s;
Minimum specifications from Chapter 1O13-6, 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 scaled.
APPROVED BY:
County Public Health Unit (CPHU) personnel reviewing and approving permit. E,
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.
2
�08: wi"(50
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID 41
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $2,90 -
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary/Experimental
[ ] Repair [ ] Abandonment. [ ] Other(Specify)
APPLICANT: cut (Z�rS.
PROPERTY STREET ADDRESS: /d r
AGENT:
LOT: BLOCK: SUBDIVISION: !
6:7 Uac !�/ roc �,t ►A
PROPERTY ID #: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
14 [OR TAX ID NUMBER]
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;-SYS.TEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
rkEPAIR 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
N
K
D
R
A
I
N
F
I
E
ft
D
�0
r[yGA�1,LON / GPD]-'SEPTICROBIC UNIT CAPACITY -,-MULTI TI CHAMBERED/ SERIES:Q[;]
[ V'�✓✓ ] GALLONS CAPACITY "'-MUhT-I-GH'AMBERED/IN SERIES:[
[ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
( j GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
] SQUARE FEET PRIMARY DRAINFIELD_SYSTEM
[ ] SQUARE FEET `"- SYSTEM
TYPE,SYSTEM: [ ] STANDARD [ ] FILLED ] MOUND [
CONFIGURATION: [ ] TRENCH a(� ] BED !)%t AkIAc "�-t'P / A '
LOCATION OF .BENCHMARK: C_111_ .g(l,C
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
FILL REQUIRED: It" ] INCHES
Cw5-72 v/= /f 3 i
] `[INCHES/FT]
]�C�HE /FT]
EXCAVATION REQUIRED: [81y ] INCHES
SPECIFICATIONS BY: TITLE:
e _
APPROVED BY:-' r!� TITLE:
DATE ISSUED:
A7-( A
ARK`/REFERENCE POINT
_40A/REFERENCE POINT
wt-; 1>eW1_111 Alwm
W t 1
Q ; .
A
CPHU
EXPIRATION DATE f ub ]!A
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0)
INSTALLER/CONTRACTOR
Page 1 of 2
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.
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 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.
STATE OF FLORIDA PERMIT #•- 'r ''• _ ;
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
New System [ ] Existing System
[ ] Repair [ ] Abandonment
APPLICANT: y 4 ,
PROPERTY STREET ADDRESS:
LOT: BLOCK•
DATE PAID f
FEE PAID $
RECEIPT#
[ ] Holding Tank [ ] Temporary/Experimental
] Other(Specify)
SUBDIVISION:
AGENT:
PROPERTY ID #: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER] '
[OR TAX ID NUMBER] �J
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCEWITH 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 [,'.r ] [GALLONS
/ GPD] SEPTIC TANK/AEROBIC UNIT
CAPACITY MULTI—CHAMBERED/IN
SERIES:[•,.]
A [' ]•-[GALLONS
/ GPD] -
CAPACITY MULTI—CHAMBERED/IN
SERIES:( ]
N [ ] GALLONS
GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS
PER DOSE DOSING TANK CAPACITY
DOSE RATE [ ] PER 24 HRS NO. OF
PUMPS: [
SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [_,-;] MOUND ( ]
CONFIGURATIONS [ ] TRENCH [^r, ] BED
a
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE ( ] [INCHES/'FT] [ABOVE/BELOW] BENCHMARX[REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ ]'[INCHES[FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
D FILL REQUIRED: [, 'r ] INCHES EXCAVATION REQUIRED: [ ] INCHES
T
H -
E `
R
SPECIFICATIONS BY:
APPROVED BY: fr
DATE ISSUED:, -
TITLE:
TITLE:
r. CPHU
EXPIRATION DATE:,
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Humber: 5744-001-4016-0)
UUILDBNQ DEPARTMENT
Page 1 of 2
— rS TRUCTIONS:
Pr %T,15 yIN13NIBER: Pcrmit tracking number assigned by CPHU.
APPLICATION FOR: Check type of pennit, 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 scaled.
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 data issued if the system has not been installed. Permits for system repairs become void 90 days from the date
issued.
I
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM :
SITE EVALUATION AND SYSTEM SPECIFICATIONS
, APPLICANT.: CURTIS UILSOA'
LOT: 2 2 BLOCK: )M 25
PROPERTY ID #:
PERMIT ,# 1 A" ) 2
�" 4 JpK
AGENT: PORT ST. LUCIE PROPERTIES/AYLOR. INC.
SUBDIVISION: Lakewood Park 04 �
[Section/Township/Range/Parcel No. or Tax ID Number]
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TO BE COMPLETED BY ENGINEER, HEALTH UNIT
EMPLOYEE,
OR OTHER QUALIFIED PERSON.
ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND
------------------------------------------------------------------------------------------------
SIGN AND
SEAL EACH PAGE OF
SUBMITTAL. COMPLETE ALL ITEMS.
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PROPERTY SIZE CONFORMS TO SITE
PLAN: [X]
YES [ ]
NO NET
USABLE AREA AVAILABLE: 119700SQ.FT.ACRES
TOTAL ESTIMATED SEWAGEFLOW:
300
GALLONS
PER DAY ..[RESIDENCES
-TABLE
1 / OTHER -TABLE 21_
••,AUTHORIZED SEWAGE FLOW:
405
GALLONS
PER 'DAY
[1500 GPD/ACRE OR
2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE:
1600
SQFT
UNOBSTRUCTED AREA REQUIRED:
924 SQFT
BENCHMARK/REFERENCE POINT LOCATION: C/L Eden Rd. -painted red "W'-elev.-10.00' assumed
ELEVATION OF PROPOSED SYSTEM SITE IS 5 K INCHES T] [ABOVELOWj'SNCH /REFERENCE POINT
/g 12 Q L'
THE MINIMUM SETIA Cr WHICH CAN BE MAINTAINED FROM E PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: 75 FT DITCHES/SWALES: � 15 FT NORMALLY WET? [ ] YES [X] NO
WELLS: PUBLIC: 200 F LIMITED USE:d% 100 FT PRIVATE: 5 FT NON -POTABLE:} 5O FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: > 11 FT POTABLE WATER LINES: N/A FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [X] NO 10 YEAR FLOODING? [ ]S [X] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: 9.6 FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
Texture Depth ,4
S to .&
1_4' �to�_
el to Z'
to :4 O
j _0_to73T-
2
137 '6 toG
to
to
USDA SOIL SERIES:
Munsell #/Color Texture Depth
to
to
to
/ to
L<p to
to
/ o to
to
USDA SOIL SERIES:
� f OBSERVED WATER TABLE: 4" INCHES [ABOVE BELOW] EXISTING GRADE. TYPE: [PERCHED / PARENT]
ESTIMATED WET SEASON WATER TE—ELEVATION: �- INCHES [ ABO / BELOW EXISTING -GRADE.
HIGH WATER TABLE VEGETATION' [ ] YES X] O MOTTLING: [ ] YES [X] NO DEPTH: INCHES
ey
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: `��}w� DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGUFtT:IOp ' _,( ] TRENCH [] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITION "CRITERIA:
SITE EVALUATEDlBY;
0'.
-D3 GIF M. AYLOR, JR.-REGISTERED LAND SURVEYOR
DATE: 4-12-96
HRS-H Form 4015,Mar 92 (Ob§oletgs.•Previous editions which may not be used) Page 3 of 3
(Stock Number: 5744-003-4015=1)
INSTRUCTIONS:
PERMIT #:
APPLICANT:
AGENT:
LOT, BLOCK, SUBDIVISION:
PROPERTY IDri':
PROPERTY SIZE:
Permit tracking number assigned by CPHU.
Property owner's full name.
Property owner's legally authorized representative.
Lot, block, and subdivision for lot.
27 character number for property. (property appraiser ID # or section/township/range/parcel number)
Check if property size at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table I (residences) or Table 2 (non-residential), Chapter
I013-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons
per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If authorized sewage flow
does not equal or exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA: Record he square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2
times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum
setbacks in Chapter 1 OD-6, FAC, The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of tha benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS: Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA"
for non applicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location
of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for site and
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must
be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and
historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted.
ELEVATION WORKSHEET
ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK
SITE I SITE 2 SITE 3
[+] SHOT:
H.I. H.I. H.I.
H.I.
[ ] SHOT [-] SHOT H SHOT