HomeMy WebLinkAboutCONSTRUCTION PERMITof
STATE OF FLORIDA r�
. DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES -
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Authority: Chapter 381, FS
QQ SCANNED Chapter.1013-6, FAC
ion By Permit Application Number;nns 4L
--------------------- PART 1—.APPLICATION --------------------------------
ie of Own I r I (p �14 C a r_U SS O Telephone Number
1 .
ng Addre s of Owner
ier's Age Qu I l (Po - V e j0 SCO Builder ,
it's Mailin Address 5 30�" SI UI (IQac Pe �PTelephone No.
erty StrGn(ee Address r
No. `1 I Block No. Subdivision t 4 Ple VCR 6 u S I n� -S ate Subdivided 3"g�
NOTE: IF NOT IN A SUBDIVISION ATTACH A METES AND BOUNDS DESCRIPTION
Applicat on is for: New System Repair Existing System
Type of Sewage Flow Sewage Flow
Establishment (Gallons per day) Based On
3
I -
TOTAL FLOW =
Type of No. Bedrooms Heated or Cooled Area No. Dwelling Sewage Flow
Residential (each dwelling unit) (each dwelling unit) Units (Gallons per day)
ll ft2
`I ft2
Exact Directions t`I Property P I f I Q n OCfkQC�
r
AUDIT CONTROL O. 0 9 713 3 Applicant's Signature _
HRS-H Fo 14015, Feb 85 (4soletes previous editions which may not be used) --
(Stock -
Nu ber:5744.001-4 -1) "` .: - gage 1 of 3 ,
I� 4
Applicant
i
�I
Septic tank or
aerobic unit
Septic tank o�
aerobic unit
Graywater
tank
Laundry
waste tank _
Ot I er Requirerr
(a) Installation
(b)i A system t
(c) Final instal
(d) { Invert of st
Invert of st
Invert of st
Invert of st
(e) Fill quality
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Authority: Chapter 381, FS St. LUCIP, �
Chapter 1013-6, FAC slq(
y
Permit Nuip, ber
-- PART I - SYSTEM CONSTRUCTION SPECIFICATIONS AND CONSTRUCTION APPROVAL -------------
Treatment Tank Minimum Draintrench OR Minimum Absorption
Size Bed Size
Grease -3i gallons interceptor gallons Square Feet Square Feet
gallons Dosing tank gallons Square Feet Square Feet
gallons Square Feet Square Feet
gallons Square Feet Square Feet
be in accord with requirements of chapter 10D-6, FAC.
uction permit is valid for a period of one calendar year from date of issue.
inspectsQ� and approval is required before the system is,.00 ered.
i
t for At e a ! I� o (� to bed �� ��� h�� ie
nchmark.
tfor to be — 1h�"'ri5`P ��� nchmarli�
t for to be benchmark.
t for to be benchmark.
quantity: A
EXCAVATION MUS`I
DRAINFIELD INSTALLATION.
o
<�DAJ 1� 5'pc�)u�r'iwrA/ii -� imosi 6- �Mn D C 1'b r In t w,
(f) Other:
System design
Note: Completed c
AUDIT CONTROL
I
W(St— Form 4016, Feb 85 (Obsol
ock Number!5744-001-4016-0)
F MUST BE GUTTERED PRIOR TO FINAL APPROVAL.
specifications
(-i
by:
County Public Health Unit
Title e,
-�%
Dated/✓ A-/9
® d'
of this form will be provided to the applicant, installer and the building department.
81655
previous editions which may not be used)
Page 1 of 2
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