HomeMy WebLinkAboutSEWAGE CONSTRUCTION PERMITCONSTRUCTION '
s; New Syst
�[ ] Repair
APPLICANT:
I
PROPERTY STR
LOT: 4 I
SCANNED
STATE OFOFLORIDA BY PERMIT #
DEPARTMENT OF HEALTH AND &He(%f SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
r FOR:
[ ] Existing System
[ ] Abandonment
ADDRESS:
BLOCK:
[ ] Holding Tank [ ] Temporary/Experiments
[ ] Other(Specify)
AGENT: , F1 litty f7 &eVW4e!S
PROPERTY IDI� [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER] u
SYSTEM MUST+IBE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
REPAIR PE ZITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE EAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
PERFORMANCFOR 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 DE81IGN AND SPECIFICATIONS
T
[ ] [GALLONS
/ P� =SEPTIC/+FUIIRQB�I UNIT---C GTTY
MULTI -CHAMBERED IN SERIES—j<T�
A
]. [GALLONS
/ GPD]`'.' CAPACITY
MULTI-CHAMBERED/IN SERIES:.[ ]
N
[ ] GALLONS
GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K
f GALLONS
PER DOSE DOSING TANK CAPACITY DOSE RATE
[ ] PER 24 HRS NO. OF PUMPS: [ ]
k D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE YSTEM, �] 9 [ ] STANDARD [ ] FILLED } MOV;4D [
I CONF GURATION> d x ,l [ ] TRENCH ;��BED �]
N ---� C -
F LOCA ION OF BENCHMARK: L D [7
I ELEV TION OF PROPOSED SYS EM SITE [ ® ] ['INt ff&S�P�![-rBOVF*BE,LOW`]aB`ENLHM-RK—t � F-&R•ENC-�E—P-O�N`r
E BOT M OF DRAINFIELD TO BE [ g n ],�/] �NOMS/F�]--f-ABOV,&/-B�E G*]- EPE-NeHNFA�it•IiY/`RL'FE`REN@E--P&I�
L
D FI REQUIRED: [ �G�] INCHES EXCAVATION REQUIRED: INCHES
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OE rs< () F r _ 51,E 1 O
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SPECIFICATIONS BY:
TITLE:
APPR VED BY' TITLE:
DAT ISSUED: JU 7
[ l
HRS- Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stork Number: 5744-001-4016-0)
CPHU
EXPIRATION DATE:
Page 1 of 2
Anne IwAuT
INSTRUCTIONS:
PERMIT NUMBER:' • Permit tracking number assigned by CPHU. v'
APPLICATION FOR: Check type of permit, if 'Other' specify type in blank.
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APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Property owner's Legally authorized representative.
! I1.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY IDk: 27 character id number for property. (CPHU may require property appraiser ID /i or section/township/range/parcel number)
SYSTEM DESIGN AND I'
I
SPECIFICATIONS: p
U
TANK:
DRAINFIELD:
OTHER:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
EXPIRATION DATE:
Minimum specifications from Chapter IOD-6, FAC.
Minimum specifications from Chapter 1013-6, FAC.
Other specifications, such as operating permit requirements, low -volume flush toilets, variance provisos.
Name of individual providing specifications. If designed by a registered engineer must be sealed. `I
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County Public Health Unit (CPHU) personnel reviewing and approving permit. I,
Date permit is issued by CPHU.
One year from date issued if the system has not been installed.
issued.
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Permits for system repairs become void 90 days from the date
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APPLICATION
New Sys
Repair
' PLICANT•
AGENT: C
MAILING ADPR
STATE 'OF F%OR€DA, .PERMIT # �, T1
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID W S� v!U-� ---_ ,
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID `$
APPLICATION FOR CONSTRUCTION PERMIT RECEIPT-#
,1
Authority: Chapter 381, FS & Chapter 1OD-6, FAC
Existing System [ ] Holding Tank [ ] Temporary/Experimental
I [ ] Abandonment [ ] Other(Specify)
TELEPHONE:
TO BE COPLE ED'BY AtPPLICANT�OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SH .WING.,PERTINE�iT,FEATURES REQUIRED BY. CHAPTER 1OD-6, FLORIDA ADMINISTRATIVE CODE.
------------ -----i=---------_----���_-------��---------------------------------^--------__
PROPERTY IN RMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: SUBDIVISION: r` DATE OF
SUBDIVISION:
PROPERTY ID '#': [Section/Township/Range/Parcel No.] ZONING:
PROPERTY SI E: o �� ACRES [Sgft/43560] PROPERTY WATER SUPPLY:®[raj—PRT'ETE PUBLIC
PIL tL
�ROPERTY S ET ADDRESS S� c T CZvw� 1
DIRECTIONS TO PROPERTY:
�;
BUILDING} NFORMATION- RESIDENTIAL;_ [ ] COMMERCIAL —
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Unit Typ of No. of Building # Persons Business Activity
No Es` blishment a Bedrooms Area Sqft Served For Commercial Only
.3
2 >
[ry'] Ga bage Grinders/Disposals [ ] Spas/,Hot Tubs [ ],Floor/Equipment Drains'
[ ] Ul, ra-loi3 Volume Flush Toilets 11' ag Other .(Specify)
APPLI C Is SIGNATURE :-Z a,&"
HRS-H.Fo m 4015, Mar 92 (obsoletes previous editions which may not be used)
(Stock NUnber: 5744-001-4015-1)
DATE:
i Page 1 of 3
INSTRUCTIONS:
APPLICATION FOM
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION:
PROPERTY ID1/:
PROPERTY SIZE:
WATER SUPPLY:
PROPERTY ADDRESS:
DIRECTIONS:
BUILDING INFORMATION:
TYPE ESTABLISHMENT:
NO. BEDROOMS:
1,
u
Check type of permit, if "Other", specify type in blank.
-T
Property owner's full name. I
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Telephone number for applicant or agent.
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it
Property owner's legally authorized representative.
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P.O. box or street, city, state and zip code mailing address for applicant or agent.
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Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision; a copy of the lot
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legal description or deed must be attached.
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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.
27 character number for property. (CPHU may require'property appraiser ID N or section/township/range/parcel number.
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. p
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Check private or public. -
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Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
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Provide detailed instructions to lot or attach an area map showing lot location. 6
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Check residential or commercial.
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List type of establishment from Table II, Chapter 1O13-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
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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 peen or fully
screened patios or decks. Based on outside measurements for each story of structure. II
N PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroo `m 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 10D-6, FAC.
FD{TURES: 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: 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, drl`' age
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waurs, and
other pertinent facilities or features on adjacent property; if the features are with 75 feet of the applicant lot. Location of Ely
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 0!
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and otfd,�r
features necessary to determine composition and quantity of wastewater.
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APPLICANT:
LOT: 1
PROPERTY ID #
STATE_ OF_a FLORIDA � PERMIT it,
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
OMSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS,"#ir
p ` AGENT: r7 '
BLOCK: SUBDIVISION:
[Section/Township/Range/Parcel No. or Tax ID Number]
-------------
TO BE COMPLETb BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER''S MUST
PROVIDE REGIS,RATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE 11 CONFORMS TO SITE PLAN: YES [ ] NO NET USABLE AREA AVAILABLE: -�(� ACRES
TOTAL ESTIMAT D SEWAGE FLOW: 6'c�o GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORI%ZED SE AGE FLOW: -A S U GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED ' A AVAILABLE: {pp SQFT UNOBSTRUCTED AREA REQUIRED: CAt-C) SQFT
BENCHMARK/REF 40POSED
ENCE POINT LOCATION: •a•ACC• N LA -
ELEVATION OF SYSTEM SITE IS '31 (INCHES�FT]
BENCHMARK/REFERENCE POINT
THE MINIMUM S TBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER[t �}� 1 FT , DITCHES/SWALES: ii + FT NORMALLY WET? [ ]'YES [k] NO
WELLS: PUBLI t arc; FT LIMITED USE: e , k- FT PRIVATE: 'lS-F FT NON -POTABLE:' L,� FT
BUILDING FO NATIONS: FT PROPERTY LINES: FT POTABLE WATER LINES: FT
SITE SUBJECTITO FREQUENT FLOODING:
10 YEAR FLOG ELEVATION FOR SITE:`
SOIL PROFILEJ�NFORMATION SITE 1
USDA SOIL
IES:
ft..S . '[>] NO 10 YEAR FLOODING? [W] YES [ ] NO'
'4TMSLY NGVD SITE ELEVATION: FT MSL/NGVDt-
G SOIL PROFILE INFORMATION SITE 2
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Texture DeDth f
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to %r; a .
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1 , to
to
to
to
to
to
Munsell #/Color Texture Depth
to
to
to
to
to
to
to
to
to
USDA SOIL SERIES:
a
OBSERVED WAT R TABLE: rr,(��t-- INCHES [ABOVE / BELOW] E%ISTING GRADE. TYPE PERCHED APPARENT]
ESTIMATED WE SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELU ] EXISTING -GRA-DN.
HIGH WATER T LE VEGETATION: [ ] YES [x] NO MOTTLING: [ ] YES [X] 90--DEPTH: INCHES -
SOIL TE%TURF LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES
DRAINFIELD NFIGURATION: [;._<}'TREN,CH [ ] BED [ ] OTHER (SPECIFY)
REMARKS/ADD IONAL CRITERIA
SITE EVALUATED BY: '; <
HRS-H Form 4015, Mar 92 (0bsoletes:0revio6s„eci,,,! ons whrch may not be used)
(Stock Number: 744-003-4015-1)
Page 3 of 3
INSTRUCTIONS:
PERMIT N:
APPLICANT:
AGENT:
LOT, BLOCK, SUBDIVISION:
PROPERTY ID//:
PROPERTY SIZE:
I' I
i
i
I
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
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 If streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water. I
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table 1 (residences) or Table 2 (non-residential), Chapter
11,
1 OD-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 tl:e estimated sewage flow, the application must be denied. Ii
UNOBSTRUCTED AREA:
Record the 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 15 percent of the unobstructed area must meet minimum
setbacks in Chapter 1O13-6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION:
II.
Record the location of the 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 bIrecorded or "NA"
for non applicable features. Features on site plan oi.within 75 feet of the applicant lot must be measured. The location
of any public drinking well within 200 feet of the applicant's_ Jot must also be verified. 1
IV
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:
AI'
Two soil profiles within the proposed absorption area to s minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textulres). Refusals muet
be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be determined.
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WATER TABLE:
6
Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
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appropriate. Record the estimated w-t 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.
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SOIL TEXTURE:
Record soi! texture or loading rate for system sizing.
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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. jl
II.
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 WORKSHEEI' ELEVATION OF BENCHMARK / REFERENCE POINT IS: -
BENCHMARK SITE 1 SITE 2 SITE 3 II
[+] SHOT: H.I. H.I. H.I. �!
H.I. [-] SHOT H SHOT [-] SHOT
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