HomeMy WebLinkAboutD O H FINAL APPROVAL(U3J OUTLET DEVICE [
[04] MULTI-CHA!p, S[
[05] LEGEND �`/�� J��
[06] WATERTIGHT [
[071 LEVEL [
108] DEPTH OF LIDS/
DRAINFIELD INSTALLATION
[09] AREA [1] [2]�y SQFT
[101 DISTRIBUTION BOX/HEADER [
[111 NUMBER OF DRAINLINES [
[12] DRAINLINE SEPARATION [
[131 DRAINLINE SLOPE
[ 14 ] DEPTH OF COVER dl12
l
[15] SYSTEM ELEVATION -1W IVl1�/I
(16] SYSTEM LOCATION [
[17] DOSING PUMPS
[18] AGGREGATE SIZE [
[19] AGGREGATE SOURCE [
[20] AGGREGATE WASHED [
[211 AGGREGATE DEPTH [
FILL/EXCAVATION MATERIAL
[ ] (221 FILL AMOUNT
[ ] (231 FILL TEXTURE
[ ] (24] EXCAVATION DEPTH
[ ] [25] EXCAVATION AREA
[ -] [261 REPLACEMENT MATERIAL
I ]
CONSTRUCTION [ OVE /DISAPPROVED]
FINAL SYSTEM APPROV /DISAPPROVED]
DH 4016, 9/96 (Replaces HRS-H Form 4016 [page 2] which may
ISlock Number: 5744-002-4016-4)
(2YJ PRIVATE WELLS
[30] PUBLIC WELLS
[31] IRRIGATION WELLS
[32] POTABLE WATER LINES
[33] BUILDING FOUNDATION
[34] PROPERTY LINES
[35] OTHER
FILLED/MOUND SYSTEM
] (361 DRAINFIELD COVER
] (37] SHOULDERS
] [38] SLOPES
] (39] STABILIZATION MATERIAL
ADDITIONAL INFORMATION
140] UNOBSTRUCTED AREA
[411 STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[441 BUILDING AREA
[45] PLUMBING FIXTURES
[46] FINAL SITE GRADING
[47] CONTRACTOR
[481 OTHER
ABANDONMENT
[ ] [49] TANK PUMPED
[ ] (50) TANK CRUSHED AND FILLED
F•
(�_1I i,__ _ r F be used) Page 2 of 2
APPLICANT
PERMIT NUMBER:
APPLICANT:
AGENT:','.
.
=c
MAILING ADDRESS:
LOT, BLOCK, SUBDIVISION
PROPERTYID#:
Permit tracking number assigned by CHD. -� r . 4
Property owner's full name.
Property owner's legally authorized representative.
P.O. box or street mailing address for applicant or agent.
Lot, Block and Subdivision for lot or
27 character number for property. (property appraiser ID # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS [X[ ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model)
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 required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
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.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OF AGGREGATE
[+) SHOT H.I. H.I. H.I.
H.I. H SHOT H SHOT H SHOT
ELEVATION