HomeMy WebLinkAboutD O H PAPERWORKSTATE OF FLORIDA�'-
-DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
--CONSTRUCTION PERMIT
Authority: 'Chapter 38I_,--FS-&-Chapter-10D-6_,_gAC
PERMIT # r;77;
DATE PAID �"
FEE PAID $ -�
RECEIPT # 7 Z
CONSTRUCTION PERMIT FOR:
'
[X ] New System [ ] Existing System
[ ] Holding Tank
[ ] Temporary/Experimental
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[ ] Repair [ ] Abandonment
[ ] Other(Specify)
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APPLICANT: Tim & Debbie Rose
AGENT:Empire
Engineering & Testing, Inc.
PROPERTY STREET ADDRESS: N/A
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LOT: BLOCK: SUBDIVISION::
SEE LEGAL ATTACHED -
PROPERTY ID#: [.SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
[OR TAX ID NUMBER] u
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SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER IOD-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 MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
.SYSTEM DESIGN AND SPECIFICATIONS
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[.].Gg(� ] [GALLONS / GPD] ROBIC UNIT CAPACITY MULTI-CHAMBERED/IN SVRTES:.[14-r
[ IZoa] [GALLONS / GPD] CAPACITY MULTI-CHAMBERED/IN. SERIES:[ ]
[ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
( ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
.SQUARE FEET PRIMARY DIM-M UEb SYSTEM.
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ X] FILLED ( X] MOUND [ ]
CONFIGURATION: [ X ] TRENCH [ ] BED
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LOCATION OF BENCHMARK: [ ACPA[ q.R Ron
ELEVATION OF PROPOSED SYSTEM SITE [ .7 ]
BOTTOM OF DRAINFIELD TO BE [ lO ]
FILL REQUIRED:,[ .3I ] INCHES EXCAVATION REQUIRED: [ 72 ] INCHES
1 Rvr �:.�to 9!1' a d.71 ♦.. ..74 �1,r t.. 1�.,.a .-,.a .-,_:� i,-.�..-- ten::
REFERENCE POINT
REFERENCE POINT
SPECIFICATY''OjFFFdSy3Br'- �' 1� .�, - TITLE:./j�
APPROVED BY' fir, .S i i `t" ' TITLE:Lt-�c7���
DATE ISSUED: "]%.,V trl .�1..+ - EXPIRATION DATE: ' S'
Y A-W?6ved n9`A
�pt� Cucte cooum( y' Health Unit
HRS-H Form 4016, Mar 92 (Obsoletes previoUk edi tFnri3 rT'14fimay *mod)
(Stock Umber: 5744-001-4016-0)
Page 1 of 2
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INSTRUCTIONS:
PERMIT NUMBER:
Perndt tracking number assigned by CPHU.
APPLICATION FOR:
Check type of permit, if 'Other" specify type in blank.
APPLICANT:
Property owners full came.
TELEPHONE:
Telephone number for applicant or agent.
AG ENT.
Property owner's legally authorized representative.
MAILING ADDRESS:
P.O. box or street trailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION _or - _ �_ - - - - - - - - - - —'--
PROPERTY IDF: 27 character id number for property. (CPHU may require property appraiser ID p or section/township/rangelparcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
Minimum specifications from Chapter 1013-6, FAC.
DRAINFIELD:
Minimum specifications from Chapter IOD-6, FAC.
OTHER:
Other specifications, such as operating permit requirements, low -volume Bush toilets, variance provisos.
SPECIFICATIONS BY:
Name of individual providing specifications. If designed by a registered engineer must he sealed.
APPROVED BY:
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 from the date
issued.