HomeMy WebLinkAboutD O H SEWAGE DISPOSAL TREATMENT - FINAL APPROVALSTATE OF FLORIDA PERMIT NO.
- DEPARTMENT OF HEALTH DAT= PAID:
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM FEE PAID:
CONSTRUCTION INSPECTION AND FINAL APPROVAL RECEIPT #:
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APPLICANTi
AGENT:
PROPERTY ADDRESS t
LOT: BLOCK: SUBDIVISION: PROPERTY ID 1:
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CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
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TANK
INSTALLATION
SETBACKS
[ l
[01]
TANK SIZE [1] [21
[
l
[27]
SURFACE WATER
FT
[ ]
[02]
TANK MATERIAL
[
]
[28]
DITCHES
FT
[ ]
[03]
OUTLET DEVICE
[
]
[29]
PRIVATE WELLS
FT
[ ]
[04)
MULTI- D [ Y / N l
I
]
[30]
PUBLIC WELLS
FT
I ]
I05]
OUTLET FILTER
I
I
[31]
IRRIGATION WELLS
FT
I ]
[06]
LEGEND
[
l
[32]
POTABLE WATER LINES
FT
[ ]
[07]
WATERTIGHT
[
]
[33]
BUILDING FOUNDATION
FT
[ ]
[08]
LEVEL
I
]
[34]
PROPERTY LINES
FT
I ]
[09]
DEPTH TO LID
[
]
[35]
OTHER
FT
DRAINFIELD INSTALLATION
FILLED / HOUND SYSTEM
[ l
[10]
AREA Iil [2] SQL
[
l
[36]
DRAINFIELD COVER
[ 7
[11]
DISTRIBUTION BOX HEADER s
[
l
[37]
SHOULDERS
I l
[12]
NUMBER OT DRAINLINES
[
]
[,38]
SLOPES
[ ]
[13]
DRAINLINE SEPARATION
I
l
[39]
STABILIZATION
[ ]
[14]
DRAINLINE SLOPE
[ ]
[15]
DEPTH OF COVER
ADDITIONAL INFORMATION
[ l
[16]
ELEVATION [ABOVE/BELOW] SM.
i
l
[40]
UNOBSTRUCTED AREA
[ l
[17)
SYSTEM LOCATION
[
]
[4'1]
STORMWATER RUNOFF
[ 7
[18)
DOSING PUMPS
[
]
[42]
ALARMS
[ l
1191
AGGREGATE SIZE
[
]
[43]
MAINTENANCE AGREEMENT
I l
[20]
AGGREGATE EXCESSIVE FINES
[
]
[44]
BUILDING AREA
I l
[2.1]
AGGREGATE DEPTH
[
]
[45]
LOCATION CONFORMS WITH SITE PLAN
[
]
[46]
FINAL SITE GRADING
FILL
/ EXCAVATION MATERIAL
I
]
[47]
CONTRACTOR
[22]
FILL AMOUNT
[
]
[48]
OTHER
[ ]
[23]
FILL TEXTURE
[ l
[24]
EXCAVATION DEPTH
ABANDONMENT
[ l
[25]
AREA REPLACED
[
]
[49]
TANK PUMPED
[ ]
[26]
REPLACEMENT MATERIAL
[
]
[50]
TANK CRUSHED it FILLED
EXPLANATION OF VIOLATIONS,' /, REMARKS t
CONSTRUCTION- JAPPROVED/DISAPPROVED]t CHD DATE:
FINAL SYSTsm [APPROVED/DISAPPROVED]t ` ':ti CHD DATEs,rf c-
DR 4016, 10/97 (Previous Editions May Be Used) Page 2 of 3
LG,AI mru n=mA 101rtAnIEur
i, 11
PERMIT NUMBER: Permit tracking number assigned by CHD.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION Lot, Block and Subdivision for lot or
PROPERTY ID#: 27 character number for property. (property appraiser ID # or GIS- location)
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION;ERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, modeQ
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
DISTRIBUTION BOX / HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (n relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as require
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (data)
AS BUILT INSTALLATION SKETCH
EXPLANATION OF VIOLATIONS: Record item number, explanation of violation, and required
CONSTRUCTION APPROVAL: Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted unit the CHD has confirmed that building construction and lot grading are in substantial
compliance with plans and specifications submitted with the permit application..
EXISTING GROUND TOP OF AGGREGATE
[+] SHOT H.I. H.I. H.I.
H.I. H SHOT H SHOT H SHOT
ELEVATION
0