32 NE 92 St (5)Date
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Ap li nt Permi umber ,P - 0 75
PAT H - YSTEM NS LLATION INSPECTION AND FINAL INSTALLATIO ` APPROVAL
Approved by:
HRS—H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002. 4016 -0)
III - Fl AL NSTALLATJON APPROVAL
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Installer - :� � � Tank Manufacturer ��1
Proper tank legend: Yes l ,V No Tank material Tank level: Yes ,l No
Tanks watertight: Yes — No Tank size: __._ gallons gallons
Proper tank outlet device: Yeses! No Manhole or marker to grade: Yes No
Drainfield Trench Absorption Bed
Length Width ##� Length Width Length 3/ feet x_/_ feet =, 3/O ft
feet feet `` .. feet feet Length feet x feet= ft
feet feet feet
feet feet feet
Total = ft Total = ft Distribution box level: Yes
feet Proper No. drainlines: Yes ✓ No
feet Proper pipe separation: Yes ± No
No
Systems located as permitted: Yes 4/ No
Systems including plumbing stub -outs installed at proper elevation: Yes / No
Average depth to drainpipe invert from finished grade 28.5 Maximum depth:,,) 2 Inches
Average depth of drainfield gravel: / 3 inches Minimum depth of gravel inches
Proper gravel size: Yes ✓ No Gravel is suitable quality: Yes No
Backfi:l or fill material as required: (Quality) Yes No (Quantity) Yes _ No
Other findings
Inspected by: , �• -C Date .�/
AN APPRO D INSTALLATION DOE OT GUARANTEE PERFORMANCE
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Zr OU NTY PUBLIC HEALTH UNIT
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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