HomeMy WebLinkAboutD O H SEWAGE DISPOSAL CONSTRUCTION PERMIT - SEPTIC TANK 9-25-97ON
,V PL I CANT •,
A
6hOPERTY STREEE
LOT: n
-'r%4 : as a 3
j STATE -OF FLORIDA,
{IDEPARTMENT OF HEALTH AND•REHABILITATIVE SERVICES
IIt ONSITE SEWAGE DISPOSAL'SYSTEM
CONSTRUCTION PERMIT
{{ Authority: Chapter 381, FS & Chapter 1OD-6-,-FAC
�PI'l Napier
PERMIT #
DATE PAID
FEE PAID
$ Y�
RECEIPT #
T FOR:
[ ] Existing.System. [ ] Holding Tank [ J Temporary/Experimental
] Abandonment [ ].Other(Specify)
ADDRESS:
SUBDIVISION:
AGENT:
Z*41
/ ® / SCANN
My
St
'PROPERTY ID #' ['SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
f� [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
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�j'MAY RESULT IN THIS PERMIT -BEING MADE NULL AND VOID.
SYSTEM DESIGNJ'AND SPECIFICATIONS
T
[ g00] GALLONS / GPD] "PTIICC TA
/AEROBIC UNIT.CAPACITY
MULTL'C'�IAiB)ERED/IN SERIES:[,]
A
[ } ['GALLONS / GPD]
CAPACITY `T-I—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
s/
[�¢] SQUARE
FEET PRIMARY DRAINFIELD SYSTEM
R
[ e ] SQUARE FEET
SYSTEM
A
TYPE SYSTEM: [ ] STANDARD [ J FILLED [� ]D
.I
CONFIGURATION:. [ ] TRENCH
N
F
LOCATION OF�
BENCHMARKA
l� �lw /?� !_
1i
_ � f�P/I
I .ELEVATION
'OF PROPOSED 'SYSTEM SITE.
_
[ ] [INCHES/FT] [ABOVE/BELO.W] BENCHMARK/REFERENCE POINT
0
T
H
E
R
SPE
BOTTOM OF DRAINFIELll
-1U` BE [. o.'.. ® [Ir4 -�FYti v_�/�l3 'L'�WJ CC NI:tiMtiiCK�K�C'CK�NI� YU1N'1'
FILL" REQUIRED:
[ ]-INCHES EXCAVATION REQUIRED:-[ g,�:] INCHES
A
LP
® i1T �R 0 C�
CIFICATIONS
BY:
h
BY: TITLE:
TITLE:"LCPHU
fJ
APPROVED
~DATE ISSUED: �F
ZS -
•_HRS-H•Form 4016, Mar 92 (Obsolet,es previous editions uhi.ch-may not be used)
tock Number: 5744-001-40.16-0)
{
APPI irAXIT
r
Page 1 of 2
INS T RUC710INS:
PERMIT I:I vfi Elt: Prrnit tracking num-er by C)'HiJ: � �
APPLICATION FOR: Check type of permit; if "Other" specify tape in blank.
APPLICANT: property owz-ier's full tame.
TELEPHONE: Telephone number for :applicant or agent.
AGEN I: PropFr�y owner's lagai'ay authorized representative.
i
,MAILING �UD D1i ESS: P.G. box or street mailing addre.xs for applicant or agent. �
LOT, BLOCK, SUBDIVISION or
PROPERTY II3": z7 character 11) number for property. (Cl'HU ;nay require property appraiser TD# or sect ionftownship/r3f;ge, parcel number.)
SYSTEM DESIGN AND I'
SPEC IPICA T IONS: i
"1'Ai`aK: Minimum specifications franc Cho ter IOD-o', FAC.
1 RAINFIELD: Minitnum specifications from Cbaptor IOD-6, FAC. i
OTI ER; Other specifications, s;�ch as oprerutin& permit requirements, low -volume flush toilets, variance pAovisos.l
SPEC.Ix ICAT IONS D Y : ;v'aatne of individual providirig sieciHcations. if designed by a registered cngia:e;!r rnust be sealed.
APPROVED BY: County Public Health Unit (C'PHU) pervunnei reviewing and approving pert it. �
BATE ISStTZD: Date permit is issued by CPHU'.
FXf'!R,V)"O`v D °T1:: Onyear aro€l date issued if he s}sae},^ hac not bcc ic,stzll>=u. pe.rnii, fc: system npzirw became Void 13 L,QV, freml the
Late issued.