HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - SEPTIC TANK - 9-8-00o� STATE OF FLORIDA PERMIT # J
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DEPARTMENT' OF HEALTH DATE PAID
x vao ONS.ITE, SEWAGE DISPOSAL SYSTEM FEE PAID
CONSTRUCTION PERMIT 'RECEIPT #
Authority: `Chapter 381, PS' & Chapter 10D-6, FAC
CONSTRUCTION PERMIT FOR:
New System [ ]' Existing System j: , ] Holding; Tank 1. ]"'Temporary/Experimental
,{ ] Repair [ ] Abandonment [ ], Other(Specify)
APPLICANT q (` AGENT:'
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PROPERTY • STR � ET ADDRESS:
_LOT: N BLOCK: s�i, SUBD,IVISION 1✓ �` �/o,
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
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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.
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SYSTEM DESIGN AND' SPECIFICATIONS
T ( ] GALLONS / GPD] SEPTIC TAN AEROBI'G UNIT .CAPACITY' MrT_I_T=AMBERED/IN,SERIES':j
B D/IN SERIES:[ ]
A [ ] [IGALLONS ,/ GPD] CAPACITY M]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250'GALLONS]
K [ 1 'GALLONS .PER DOSE DOSING TANK CAPACITY DOSE -RATE [ ] PER 24 HRS NO. OF PUMPS: [ ']
D [�j SQUARE FEET PRIMARY DRAINFiELD SYSTEM
R. [ ] . 5QUARE FEET SYSTEM
A TYPE SYSTqM: [ ]'STANDARD 1 ] FILLED' ] MOUND/y
I CaNFIGURA ION: [ ] TRENCH [] BED
N %� / �,� /�C % n ,/✓
Ft `LOCATION' OF ' BENCHMARK
1 ELEVATION OF PROPOSED SYSTEM SITE [ 1 [INCHES/FT) [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
,rE ,BOTTOM OF D_RAINFIELD TO BE [ J INCHE /FT] [,ABOVE /REFERENCE 'POINT
D. FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [] INCHES
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',SPECIFICATIONS,BY: TITLE':
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APPROVED'BY: a TITLE: r-P
DATE ISSUED: a' s Y — r EXPIRATION DATE:
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DH 4076, 10196,(Repiaces HRS-H Form 4016 [page 11 which may be used) Page 1 Of 2
(Stock Number: 6744-0 14016-0) Applicant
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: ' 27 character ID number for property. (Health Department may require property appraiser ID# or '
sectiori/township/range/parcel number.) i!
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter IOD-6, FAC.
DRAINFIELD: Minimum specifications from Chapter IOD-6, FAC.
OTHER: Other specifications, such as operating permit requirements, low -volume flush toilets, variance provi
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. I
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DATE ISSUED: Date permit is issued by County Health Department. j y
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. �� e
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