HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - 7-26-99<Q6:;2-11SmPf
STATE -OF FLORIDA PERMIT #- -�
DEPARTMENT -OF HEALTH AND REHABILITATIVE SERVICES DATE<PAID
ONS-ITE SEWAGEDISPOSAL SYSTEM FEE PAID $ V00
CONSTRUCTION PERMIT RECEIPT #
Authority: 6hapter,381, FS & Chapter 1OD-6, FAC
CONSTRUCTION PERMIT FOR:
[ VeNew Syst`m [ ] Existing System j ] Holding Tank [ ] Temporary/Experimental
j. ] Repair. �. [_ ] Abandonment [ ] Other.(Specify)-
APPLICANT: 090Z I +(_V� ]W4 701-01 AGENT: P-SI- ngajo
PROPERTY STREET ADDRESS:
LOT: BLOCK: SUBDIVISION: rLUCie
PROPERTY ID #"' [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]`
[OR TAX ID NUMBER]
=,;i __
SYSTEM MUST BE'CONSTRUCTED.-IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
REPAIR PERMIA 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.
a
SYSTEM DESIGNr[AND SPECIFICATIONS
T [ . Y00 ] (G�ONS�y GPD] -SEP-IC TAN�AEROBIC UNIT CAPACITY <MUL�TI-CH BAM ERED-/5N SERIES:
A [ t . ] '[GALLONS / GPD] CAPACITY MULTI=CHMEERED/SIN SERIES:[ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY" [MAXIMUM CAPACITY SINGLE TANK:.1.250 GALLONS]
.K [ J. GALLONS-PER".DOSE DOSING TANK CAPACITY' DOSE -RATE"[ J PER 24 HRS NO. OF.PUMPS: [:]
D [ t-16 9 ] S
R [ ] S
A _'TYPE SYSTE
I, CONFIGURAT
N
F 'LOCATION O
I_ ELEVATION
E BOTTOM, OF
L
D FILL- REQUI
.0 XA1 V
T.
H
_E l -/P
R
SPECIFICATIO:
-APPROVED BYY.
DATE ISSUED:
UARE FEET PRIMARY DRAINFIELD SYSTEM
UARE FEET . SYSTEM
{ ] STANDARD [ -] FILLED
ON: [ ]. TRENCH [ 0I,--BED
[]MOUND ,[ ]
BENCHMARK: NML i4 PINC 7REC Z � �� AAalll, F)(Jt.TrNG 61?4DL•"
`PROPOSED SYSTEM` SITE. [ j` .] I_RC ETS�/FT] [ABOVFa/BELOW:] EIHMA'RREFERENCE POINT -
AINFIELD. TO`'•BE [ ] 'INCES, FT] f �fB V BELOW] BENCHMARK REFERENCE POINT
[yfS ] I=N H EXCAVATION REQUIRED: [fL)S' ] INCHES
BY: TITLE:
TITLE:
^Js CPHU
EXPIRATION DATE: 7-2-6 jei
HRS-H Form-_4016,
(Stock Number:
r 92 (Obsoletes previous editions which may not be used)
4-001-4016-0)
APPLiC`At�ffi'=
Page l'of 2
c
INSTRUCTIONS:
PERMIT NUMBER:
Permit tracking number 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.
A_GE ,T- ;`': ,
Property owner's legally authorized representative.
MAIj.1 C, jDb SS:
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/fa
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK-
Minimum specifications From Chapter IOD-u', FAC.
DRAINFIELID:
Minimum specifications from Chapter IOIJ-&, FAC.
OTHER:
Other specifications, such as operating permit requirements, low -volume flush toilets, variance provisos.
SPECIFICATIONS BY:
Name of individual providing specifications. If dcsigned by a registered engine r must be seated.
APPROVED BY;
County Public Health Unit (CI?SIU) personnel nevi: wing and approving permit.
DATE ISSUED:
Date permit is issued by CPHU.
EXPIRATION DATE:
One year from date issued if the sy.tari: has not bccn instalied. Permits for system repairs becorne void J
date issued.
number.)
days from the