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HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - SEPTIC -1-10-96rad le 110. / y 1_' o \_ A ®C>l STATE OF FLORII DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES'. ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION'PERMIT Authority: Chapter 38.1, FS & Chapter 1OD-6, FAC PERMIT # DATE PAID FEE PAID. $ 7,010 o CEI7T # _ i CONSTRUCTION PERMIT FOR: [ ] New Sy�tem ( ] Existing System [ ] Holding Tank { ]- Temporary/Experimental [ ] Rl epairj [ _] Abandonment [ ]`Other(Specify) APPLI CANT : q',BQ , / j , AGENT: �p�l ho p. 119d, 101. . C ° PROPERTY ESTREET ADDRESS: � Au z® -Av 9 LOT: BLOCK:- SUBDIVISION:, PROPERTY-IDi#: [SECTION/TOWNSHIP/RANGE/PARCEL.NUMBER]- i [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D-6, FAC REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER 'PERMITS HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY EXPIRE ONE YEAR FROM THE DATE OF ISSUE. 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. I_________________________________________________ e�== SYSTEM DES2GN AND SPECIFICATIONS Sf�UG@ C0417f T GALLO / GPD. SEPTIC TANK/ EROBIC UNIT CAPACITY q1CNl[JLTI�CHAMBERED /�N SERIES: [ ]� A [ ✓ '�] ,[GALLONS / GPD] CAPACITY MMULT11-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 [ 2 J ',SQUARE FEET PRIM A- Y DRAINFIELD . SYSTEM R } .[ ] SQUARE FEET SYS EM, A TYPESYSTEM: [ ] STANDARD [- ] FILLED MOUND [ Lf I CONFIGURATION: -[ ] TRENCH (of] BED ['] 2+� N F I E L D 0 T H E R SPE API DA7 ,: HRS- (St< LOCATION IOF BENCHMARK: K� L.. IL" I ELEVATION OF PROPOSED SYSTEM SITEI. [ 6 ] `Y2EFERENCE POINT tsUTTUP1 Ur-, 1JICA11Vr-1r;LU. -1"U Dr, L .. �j-- L......r,..:���,r.• AU L.�.�., v. ,:,'„—..,J.,.., REQUIRED: [ ] ZNGH-ES EXCAVATION REQUIRED: [ �] INCHES _ YaFILL I 19!AREA OF DRAINfIEI_D IS SU ` �— R jlp FROM ROOF DRAMAC CIFICATIONS 'SM1 ROQF RAWUTT €D PRIOR TO 4 BY: TITLE: ' "{.- FIND AR ROVED BY: f� TITLE: % CPHU 'E ISSUED: // I/! 6 THIS PERMIT IS ISSUED BASE ON AN DATE:,��� ` APPLICATION MADE FOR A THREE (3) BEDROOM PRIVATE RESIDENCE. ANY H Form 4016, ar 92 (Obsoletes previous editions which may not. beC`kOrIONAL USE OF DEN"STUDY, -AS A BEDROOM STUDY,__ OR QTHER RE- Page 1 of -2 ck Humber: 5744-001.-4016-0) WILL VIOLATE SYSTEM DESIGN AND APPLICAWY CAUSE SYSTEM FAILURE INSTRUCTIONS: PERMIT NUMBER: Permit tracking number assigned by CPHU. APPLICATION FOR: Check type of permit, if "Other" specify type in blank. I APPLICANT: f Property owner's full name. TELEPHONE: r Telephone number for applicant or agent. I AGENT: ` Property owner's legally authorized representative. I MAILING ADDRESS: P.O, box or street mailing address for applicant or agent. . . 1 LOT, BLOCK, SUBDIVISION or I PROPERTY IDN: 27 character id number for property. (CPHU may require property appraiser ID # or section/township/range/par< SYSTEM DESIGN AND I SPECIFICATIONS: TANK: Minimum specifications from Chapter IOD-6, FAC. I DRAINFIELD: Minimum specifications from Chapter 1013-6, FAC. OTHER: Other specifications, such as operating permit requirements, low -volume flush toilets, variance provisos. SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed. J APPRQV.ED BY:J I� County Public Health Unit (CPHU) personnel reviewing and approving permit. - +DATE ISSUED: Date permit is issued by CPHU. EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void 90 days JI issued. u 1 number) from the date