910 NE 91 Terr (10)STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[I New System [ Existing System
[ 1 Repair [ Abandonment
APPLICANT: 111 14)+4
,f
PROPERTY ADDRESS:
LOT: kik BLOCK: PJ / ) SUBDIVISION:
PROPERTY ID #: � +� b �} + P Cf - fl a s Q [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
T
A
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SYSTEM DESIGN AND SP CIFICS
1 o,-"N
[5 4 ] GALLONS / GPD AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
[ ] GALLONS / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
[ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
[ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS ® [ ] DOSES PER 24 HRS # PUMPS [ ]
(3O ] SQUARE FEET PRIMARY D
[ ] SQUARE FEET
TYPE SYSTEM: STANARD
CONFIGURATION: [ TRENCH
LOCATION OF BENCHMARK: 7RO
ELEVATION OF PROPOSED SYSTEM S
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED: [ /J i t ] INCHES
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DH 4016, 12/99 (Page 1) (Prevlious
[A]
J J /c
,/ crerneer
RAINFIELD SYSTEM
SYSTEM 7
[ AI FILLED A6]` MOUND
[14 BED [
ITE [!.
EXCAVATION REQUIRED:
TITLE:
,:s. {0 t l alb itii 47,AL .; ON TIE War PA
pt. 2: Applicant
pt. 3: Installer /Contractor
pt. 4: Building Department
Holding Tank
Temporary
M 171.- [SECTION, TOW H IP, RANGE, PARCEL NUMBER]
[ABOVE/ - ? O" �. BENCHMARK /REFERENCE POINT
/FT] [ABOVE /B= •W] BENCHMARK /REFERENCE POINT
TITLE:
INCHES
IN3TALL CC.:.", 1 Sz..t•;ii
UND :ri 13Oi i Q .1 Cl
T441S is NOT i'
iNv rr E! EVI T ON
BOTTOM CF D :NF!aD EL ?.y ' 1l I N
Qki tab
PERMIT NO. QJ - �.3 7 AL
DATE PAID: , _ 3 s _ I
FEE PAID:
RECEIPT #:3 % 8 j 5
I 3_ Q
("4
Vvri
EXPIRATION DATE:
Innovative
/3r e NC) k
Page
1 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT 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. (CHD may require property appraiser ID # or section /township /range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 64E -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 64E-6, FAC.
OTHER: Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department (CHD) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CHD
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.
CONSTRUCTION PERMIT FOR:
VA] New System (I+ Existing System
[ ] Repair [/t Abandonment
APPLICANT:
PROPERTY ADDRESS:
LOT: 1
0
T
H
E
R
SPECIFICATIONS BY: .00
APPROVED BYI
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT •
ffI 6'
BLOCK: M f
(/`-A
[/1
iIkif C 7
,/ erv
SUBDIVISION:
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
PROPERTY ID #: _i t —,e 4)6„ s 0_ 3 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SP CIFICA IO S
T [ l''''] GALLONS / GPD Vd=MSIAEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
A [ ] GALLONS / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ]
D [140943 ] SQUARE FEET
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION:
N
F
I
E BOTTOM OF DRAINFIELD TO BE
D FILL REQUIRED: [Alit ] INCHES EXCAVATION REQUIRED:
PRIMARY DRAINFIELD SYSTEM
/ SYSTEM )
] STANARD [ A,1 FILLED / [ d MOUND
TRENCH [id BED [ ea
LOCATION OF BENCHMARE:1;i4ifftll ra 3 1 4
ELEVATION OF PROPOSED SYSTEM SITE [ /461] [IS
65 4:V-
TITLE:
DH 4016, 12/99 (Page 1) (Previo*U , 241,,440#;artB, Us ed)`.'
• pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer/Contractor
pt. 4: Building Department
Holding Tank
g [/WI Innovative
Temporary 600„/r
1
utA
[ABOVE / BENCHMARK /REFERENCE POINT
/FT] [ABOVE /B W] BENCHMARK /REFERENCE POINT
[ 2 . (t,/ ' N { '
INSTALL f>ICOF tram t ,A'RS5 SAND
tlr 1EZFR BOTTOM O D^.AINFJ WD
CUBMIT BENCHMARK BE.FCnE 1N;,FF.CTION
THIS PERMIT I3 NOT FO Mr' co
IN , 1wirowr :11L.
p1 1 UM LA 3RAINFtf=t.D E ATION 1/>t
TITLE:
PERMIT NO. 0/, p �, r' 7
DATE PAID: y s,7 _ 1/
FEE PAID: ) 3
RECEIPT # : ff ' /
S - <;
S I +"-1 () #
EXPIRATION DATE:
Page 1 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT 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. (CHD may require property appraiser ID # or section /township /range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 64E-6, FAC.
DRAINFIELD: Minimum specifications from Chapter 64E-6, FAC.
OTHER: Other specifications, such as operating permit requirements, low - volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department (CHD) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CHD
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.
Date 1 -1 1- 59 /Job Address ' /DA✓C Q /JT Tom. /'CL Tax Folio l/ 3 .'O4 OZ3V 0020
1 917zF'7 O /et. ` .7z= NL '/ i Op a2= i, GL - J1
Legal Description Historically Designated: Yes /( No
Owner/Lessee / Tenant 7/ /0U / &A/r Master Permit # "/ g 9/S
Owner's Address 9/0 &JL 9457 Phone ' � J --zrz
Contracting Co. L L oy/ /1/CM7/ DH PT/G Address '73 /1). Gl) /O /7 Si 1/ )
Qualifier L C.57 L'""- ORCIO 7 ss# - - Phone gar 9S/ 7
State # c5,q Ogg p" Municipal # 7 3t • tT Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION ? LP /R I r--- KA //1/ F, G
Square Ft. '
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER
OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I certify that all work
will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required for ELECTRICAL
PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate an that all work will be done in compliance with all applicable laws regulating
construction and zoning. Furthermore, I authorize the above -named contractor t do the work gtated.
Si owner and/or ondo President Date
Notary as to • - an or ondo President Date Notary as t. Con actor or Owner- Builder Date
My Commission Expires:
APPROVED:
Zoning Building
Mechanical Plumbing
7 O- 0f
Estimated Cost (value) 4 /
Signature of Con
My Commission Expires:
C.C.F. Z� NOTARY BOND a
TOTAL DUE 3
Electrical
Date
Structural Engineer
Location and Legal Description Lot_
Amount of Permit $
STATE OF FLORIDA,
COUNTY OF DADE.
2 /, , oe
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLCATION FOR PLUMBING PERMIT
Permit No.__.( Date. __I 2 43 ./. O
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other •
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address ____. __________ ____ Ai _L ___ Street.._. /
Registered Architect and /or Engineer _— � � - -._— _------ -- .----- - -. - -
Employing Plumber's Name -- ( � - S y � _ ` y �'� _'�� —' - - No.. � 6 1 � L_ ! � ! -- -Street_. -2- Gam'
B1oek
Street and Number where work is to be performed —No .f / A1.fr
State work to be performed and purpose of building (By Floors)
New Building_ -- _--- _--- --- .-- -•_ -- Remodeling—___ —__ -- Addition__--- __ --._ Repairs
( Signed) - - -__ -_ _
Size Septic Tank_--- --------------- - -- - -- -Type of Tank -- - ------ ____ -. - - -- - --
Feet of Drain Tile________ —_ — ___— _Dist. Feet of Tank or Drain Field from Well.
Nature of Water Supply: City — Well ___— __— __— __-- ________— ___Size of Soakage Pit
Street �l✓'
bing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has corn-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
__Capacity Gals
Jam
No. of Stories..
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the_ _..
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Florida
Master Plumber.
NOTE: A re-inspection fee of $1.00 will be made when such re- inspection is made 'necessary by improper notice for insp qn, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
OWERS
SHOWERS
LAVA
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBS
I NALS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING DRINK
FOUNT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LIST
3 1 °1
- --
CHECK
Location and Legal Description Lot_
Amount of Permit $
STATE OF FLORIDA,
COUNTY OF DADE.
2 /, , oe
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLCATION FOR PLUMBING PERMIT
Permit No.__.( Date. __I 2 43 ./. O
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other •
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address ____. __________ ____ Ai _L ___ Street.._. /
Registered Architect and /or Engineer _— � � - -._— _------ -- .----- - -. - -
Employing Plumber's Name -- ( � - S y � _ ` y �'� _'�� —' - - No.. � 6 1 � L_ ! � ! -- -Street_. -2- Gam'
B1oek
Street and Number where work is to be performed —No .f / A1.fr
State work to be performed and purpose of building (By Floors)
New Building_ -- _--- _--- --- .-- -•_ -- Remodeling—___ —__ -- Addition__--- __ --._ Repairs
( Signed) - - -__ -_ _
Size Septic Tank_--- --------------- - -- - -- -Type of Tank -- - ------ ____ -. - - -- - --
Feet of Drain Tile________ —_ — ___— _Dist. Feet of Tank or Drain Field from Well.
Nature of Water Supply: City — Well ___— __— __— __-- ________— ___Size of Soakage Pit
Street �l✓'
bing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has corn-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
__Capacity Gals
Jam
No. of Stories..
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the_ _..
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Florida
Master Plumber.
NOTE: A re-inspection fee of $1.00 will be made when such re- inspection is made 'necessary by improper notice for insp qn, or faulty
materials and /or workmanship.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: 70 Ats 4'AJ/(r/L /T AGENT: tz U ro /✓ 7 -4/
p '�foF. / �/= F1 /l°�i� 0/= � %�.o��uBi�� s Imo tr N..� � Sc- LL 5.5 Al /0 F
PROPERTY ID #: //- X" 0 / - .00.20 [Section /Township /Range /Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
SOIL PROFILE INFORMATION SITE 1
ELEVATION OF PROPOSED SYSTEM SITE IS
BENCHMARK /REFERENCE POINT LOCATION: F1/Li/d5 A' /1
a /10
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: /I i-1 FT DITCHES /SWALES: 4,1.4. FT NORMALLY WET? [ ] YES/t/4( ] NO
WELLS: PUBLIC: /1J./ -. FT LIMITED USE: 414. FT PRIVATE: /V4 FT NON- POTABLE: jO FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: 3 FT POTABLE WATER LINES: /.Q FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [14NO 10 YEAR FLOODING? [ ] YES VINO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: 1/4' MSL GVD
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color
/Q ‘4R
/0 A YR 6g/g),
/t
//
/ 1
/!
USDA SOIL SERIES:
Texture Depth
top my 0 4 to
LA IUD to /O /i
5)JNP /Of to
to
/I to
// to
to
/1 to
1 3 lA )L /ln-U
OBSERVED WATER TABLE: /M• INCHES [ABOVE / BELOW] E ISTIN E. TYPE: ERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: /07 - - NCHES,. ABOVE BELO EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [ {NO MOTTLING: [ ] YES [(NO DEPT: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: :/. 0 DEPTH OF EXCAVATION: AO INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [ / .. ] BE [ ] OTHER (SPECIFY) .1
REMARKS /ADDITIIO)AL CRITERIA: ` , '"/
.)
SITE EVALUATED BY:-..-714 0 1
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 31 which may be used)
(Stock Number: 5744- 003 - 4015 -1)
PERMIT #
YES [ ] NO NET USABLE AREA AVAILABLE: AO ACRES
GALLONS PER DAY ES'T N ES- TABLE' / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE ORC1500 GPD /ACR
SQFT UNOBSTRUCTED AREA REQUIRED: ij SQFT
FT] [ABO
ELO
ENCHMARK /REFERENCE POINT
Munsell /Color Texture Depth
/0 vk i// L,'.,v /y CY/ to
GRAY ,S� QD to 0)
/0 YR =7/ . ;VW D /' "/ to
(•r /�y 514/2)D to
// // to
/I /I to
i/ / ► to
1/ // to
// // to .'Ja / '
USDA SOIL SERIES _ l AJ L/M)
1
•
DATE: 1 • ® /'/
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential),
Chapter 10D -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: if applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE I SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. [ - ] SHOT [ - ]SHOT [ - ]SHOT
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN -
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes:
STATE OF FLORIDA
OF A I . Q/5
Site Plan submitted by:\)
Plan Approved
DH 4015, 10/96 (Replaces HRS.H Form 4015 which may be used)
(Stock Number: 5744 - 002 - 4015-6)
,l yG Oita
it
v trYT 0 146'
DR
-
&:--,97- et, C-7 N>
the
Date DO A l
By c _ -&'l-, 4 )I*6 ' County Health Department
ALL CHANG - MUST Bg APPROVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 3