HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - 9-5-98:�T•oS a°`1; K tce-
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HE D REHABILITATIVE SERVICES DATE PAID � CO "
eUU
LONSITE SEWAGE DISP��SYSTEM FEE PAID $ _
CONSTRUCTION PERMIT RECEIPT #
Authority: ChapterANOVWS & Chapter 1OD-6, FAC SCANNOn
BY (L�
CONSTRUCTION PERMIT FOR: StLudeCc)U'VExperimental
1V
] New System ( ] Existing System [ J Holding Tank [ ]'Temporar
[ ] Repair' [ ] Abandonment [ ] Other(Specify)
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APPLICANT. ® AGENT:._j
PROPERTY STREET ADDRESS: C f%
LOT: BLOCK: SUBDIVISION: P
PROPERTY IDI #: [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER]
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SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D-6, FAC
REPAIR PE ITS AND HOLDING, TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE IYEAR 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 IiSSUANCE 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
[ 90D ]
[GALLONS
/ 90-1 SEPTIC TANK/i'EI>L~ 3' +b''
�A`F'A'C Y MULTI —CHAMBERED/ SE}R14m. [ ]
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: [
D
R
A
I
N
F
I
E
L
D
SPI
API
[q (0,3]�SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] UND �[ ]
CONFIGURATION: [ ] TRENCH [] BED ]
r
LOCATION OF BENCHMARK: c_
ELEVATION OF PROPOSED SYSTEM SITE [ 3,? ] [INCHE / ] r G /B&OW] BENCHMARK/ NG
BOTTOM OIL' DRAINFIELD TO BE [ (a] [INCHES/WY] [ABOVE �BE♦ O BENCHMARK/REd' T
FILL REQUIRED: [�] "iNCHEB r EXCAVATION REQUIRED: [ ] INCHES n
191 ELF
CIFICATIONS
ROVED BY
Ii
DATE ISSUED'
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I
HRS-H Form 4016,; Mar 92 (obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0)
EXPIRATION DATE:
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: $raiieit} ,owner's full name.
TELEPHONE: Ee�ephone'mtenb4r for applicant or agent.
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i
AGENT: Property o:vrer's legal!y authk—lized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY IDYr: 27 character id number for property. (CPHU may require property appraiser ID N 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.
„ I
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer nmust be sealed.
APPROVED BY: County Public Health Unit (CPHU) personnel reviewing and approving permit.
D�.Tf,j� UED: Date permit is issued by CPHU. 4
-. sa . -n• ,-n.ar ..-a Tip_.; .. _. ....... �w;
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.
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