HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - 2-5-99 - SEPTIC TANKerr
STATE OF FLORIDA PERMIT # ,:1
F - j DEPARTMENT OF HEALTH DATE PAID JA��
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID
CONSTRUCTION PERMIT RECEIPT #
•�coDWV0 Authority: Chapter 381, FS & Chapter 10D-6, FAC
CObfSTRUCTION';PERMIT FOR:
[ I New System' [ ] Existing System [ ] Holding Tank [ ] Temporary/Experimental "
(] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT: ;, AGENT:
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PROPERTY STRI"ET ADDRESS: 6 r / li 9 1 �y`�/V/ ED
LOT: -7 BLOCK: i SUBDIVISIONS
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PROPERTY ID #: [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;'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
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.
I;
SYSTEM DESIGN AND SPECIFICATIONS
T [ ] �m,GA-=ON�S / GPD] -EPT�C-TANK{ AEROBIC UNIT CAPACITY CMULTI-C-H-MBERRUZIN SERIES: [ ]
A [ ` ] [CALLOrN GPD J CAPACITY `MTTiT --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 [ �j ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION:1c 12 [ ] TRENCH [�J, BED [ v�
N l! _ _ Q i S�� �� IPY r� 0 (`� 1b SQ 1(_1
F LOCATION OF BENCHMARK: r
I ELEVATION;'OF PROPOSED SYSTEM SITE [ `�[®INC-3 F ej E[ i0VE7BELOW] RENCHRARK-/REFERENCE POINT
E BOTTOM OF jDRAINFIELD TO BE [ / ] [� CHESFT] IBOVE` S/:BELOW] EENC GHMIRK/REFERENCE POINT
L
D FFILL REQUIRED:"[ S ] INCHES EXCAVATION REQUIRED: [ o f ] INCHES
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SPECIFICATIONS BY: TITLE:
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APPROVED BY:' TITLE:
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DATE ISSUED:,'
DH 4016, 10/96 (Replaces HRS-H Form 4016 [page 11 which may be used)
(Stock Number: 5744-001-4016-0)
Applicant
/ A \ CHD
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EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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.
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
section/township/range/parcel number.)
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 proviso
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.
DATE ISSUED: Date permit is issued by County Health Department.
i
EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void)
date issued. I
) days from the