HomeMy WebLinkAboutSEWAGE CONSTRUCTION PERMITSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS& Chapter 1OD-6, FAC
C04STRUCTION PERMIT FOR:
t ] New System [ ] Existing System
[ �] Repair [ ] Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
PERMIT '#
DATE PAID
FEE PAID $
RECEIPT # - -
[ ] Holding Tank [ ] Temporary/Experimental
[ ] Other(Specify)
AGENT:
,r
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. DEPARTMENT OF HEALTH 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 [
] [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: [ ]
[s ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ) MOUND [ ]
CONFIGURATION: [ ) TRENCH j ] BED [ ]
LOCATION OF BENCHMARK: Y
ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
r .
SPECIFICATIONS BY:
TITLE:
APPROVED BY: TITLE:
DATE ISSUED:
EXPIRATION DATE:
DH 4016, 10/96 (Replaces,HRS-H form 4016 [page 11 which maybe used) Page 1 Of 2
(Stock Number: 5744-001-4016-0)
Building Department
1 •
INSTRUCTIONS:
PERMIT NUMBER:
Permit tracking number by County Health Department.
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.
1
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#:
27 character ID number for property. (Health Dep Irtment may require property appraiser ID# or
section/township/range/parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter I OD-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 Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.