685 NE 93 St (3)APPLICANT
AGENT
PROPERTY ADDRESS: S / r ' l 3
LOT: 1
BLOCK E: 5 SUBDIVISIONi. .r
CHECKED [X] ITEMS ARE NOT IN COMPLIANCF. WITH STATUTE OR RULE AND MUST BE CORRECTED.
CONSTRUCTIO
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPO
CONSTRUCTION INSPECTION AND FINA
TANK INSTALLATION
[01] TANK SIZE [1] [2]
[02] TANK MATERIALC3� --u�'
[03] OUTLET DEVICE
[04] MULTI - CHAMBERED [Y /f]
[05] OUTLET FILTER .?/'
Jr
[06] LEGEND
[07] WATERTIGHT_
[08] LEVEL A/ f-4
[09] DEPTH TO LID //j '/
DRAINFIELD INSTALLATION
[10] AREA [1]/1 X2S' [2] (5 SOFT
[11] DISTRIBUTION BOX HEADER"
[12] NUMBER OF DRAINLINES
[13] DRAINLINE SEPARATION ,3‘
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER /8' ' '
[16] ELEVATION [ABOttet8ELZ7W�BM / • �!
[17] SYSTEM LOCATION_
[18] DOSING PUMPS
[19] AGGREGATE SIZE S° a
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPTH / ,
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT /.'
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
'Page 2), 10/97 (Previous Editions May Be Used)
her: 5744- 002- 4016 -4
:o6 - 1205
e
TEM
VAL
� 7
/DISAPPROVED1 A k' r) C
FINAL SYSTEM LAPPROVED /DIS PPROVED]: ' �-
PERMIT NO.0 1 y -
DATE PAID
FEE PAID -
RECEIPT #-
PROPERTY ID #:
SETBACKS
[27] SURFACE WATER N / 4- FT
[28] DITCHES FT
[29] PRIVATE WELLS / FT
[30] PUBLIC WELLS FT
[31] IRRIGATION WELLS 'V /4 FT
[32] POTABLE WATER LINES Z i' FT
[33] BUILDING FOUNDATION 5 FT
[34] PROPERTY LINES / t. FT
[35] OTHER FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
FINAL SITE GRAD
CONTRACTOR
OTHER
PT 1: Appticanl
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
1
ADDITIONAL INFORMATION
UNOBSTRUCTED AREA
STORMWATER RUNOFF
ALARMS
MAINTENANCE AGREEMENT
BUILDING AREA
LOCATION CONFORMS WITH SITE PLAN
ABANDONMENT [
[49] TANK PUMPED '� /� q/
[50] TANK CRUSHED & FILLED_/
CHD DATE 5 - /h ^ G'
CHD DATE: _ ` -
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