695 NE 93 St (2)CONSTRUCTION PERMIT FOR:
[/J] New System [/)] Existing System [Ai] Holding Tank [AJ] Temporary /Experimental
[2(1 Repair [ )J] Abandonment [N ] Other(Specify)
T
A
N
K
0
T
E
R
APPLICANT:
PROPERTY STREET ADDRESS:
'/
PROPERTY ID #:
LOT:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: 3/2 0 47
U
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6, Fi
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMI'
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTOR)
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. SUC
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFICATIONS
[fJ01.
[ ]
[GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[
[GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[
GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLON:
GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [
D [ 2 00 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ — ] SQUARE FEET J SYSTEM
A TYPE SYSTEM: [✓ ] STANDARD [ ]/FILLED [
I CONFIGURATION: [ ] TRENCH [ BED [
N
F
I
E
L
D FILL REQUIRED: Wit- INCHES
LOCATION OF BENCHMARK: Pv0 ✓1 C ,ePI.IchivrCi�/K ELQ 214e �“ T' rp
ELEVATION OF PROPOSED SYSTEM SITE j � ✓/i ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN
BOTTOM OF DRAINFIELD TO BE [ / /9 ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN
HRS -H Form 4016, Mar 92 (Obsoletes previous
(Stock Number: 5744-001- 4016-0)
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
AGENT:
/a A,os4 se'r�r 20 & -)-
BLOCK: SUBDIVISION: /(1/44
It //9
[ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
EXCAVATION REQUIRED:
<1983 INSTA,LT.: f?' Y.rI,'ri y MARSF SA n
BOTTOM r,7. ; 4 . 5.2 - s C -
BEN CTii��A x�' ' ;, `;...
NOT FOR ADDITiON
TITLE:
TITLE:
(.., K (J-
editions which may not be used)
MOUND
[ 3p]
PERMIT # 9S42 - p/l
DATE PAID 3 - 17 -'1 '
FEE PAID $ 40-0 0
RECEIPT # k / 01
INCHES
CPH1
EXPIRATION DATE: 0 a / G
Da
•
Page 1 of :
APPLICANT:
PROPERTY
LOT:
'PROPERTY'•ID #:
/
�
STREET ADDRESS: � (,
1 -'
BLOCK:
TANK
[41 TANK SIZE [1]
[02] MATERIAL
[03] OUTLET DEVICE
[04] MULTI— CHAMBERS
[05] LEGEND
• [06]: WATERTIGHT
[07] LEVEL
[08] DEPTH OF LID
[
i64 - r t '
DRAINFIELD INSTALLATION
[091 AREA [1 p /
[10].DISTRIBUTION BOX /HEADER
[11] NUMBER OF DRAINLINES
[12] DRAINLINE SEPARATION
[13] DRAINLINE SLOPE J)
[14] DEPTH OF COVER G7.,
[15] SYSTEM ELEVATION
[16] SYSTEM LOCATION
[17] DOSING PUMPS
[18] AGGREGATE SIZE
[19] AGGREGATE SOURCE
[20] AGGREGATE WASHED
[21] AGGREGATE DEPTH
FILL /EXCAVATION MATERIAL
[22] FILL AMOUNT
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] EXCAVATION AREA
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS:
SUBDIVISION:
nLJ 5 s�
J
CONSTRUCTION [APPROVED/DISAPPROVED] : /-'v P2 /(( rii
FINAL SYSTEM ' [APPROVED /DISAPPROVED]
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not
(Stock Number: 5744 - 002 - 4016 -4)
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Authority: Chapter 381, FS & Chapter 10D -6, FAC
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
SQFT
AGENT: \
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER] .
[ ; ] [
[f ] [
( ] [29]
((/1 [
[ ] [31]
[ ] [
[ [34]
[34]
C, 1 [35]
be used)
SETBACKS
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
P1111 fIM(; IIPPARTMFNT
SURFACE WATER
DITCHES
PRIVATE WELLS
PUBLIC WELLS
IRRIGATION WELLS
POTABLE WATER LINES
BUILDING FOUNDATION
PROPERTY LINES .
OTHER
FILLED /MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION MATERIAL
ADDITIONAL INFORMATION
ABANDONMENT _
]
[49] TANK PUMPED _ / / -) /
] [50] TANK CRUSHED AND FILLED
S 4-'' U `i1_ •
l:'; -
PERMIT #
RECEIPT # _
FEE PAID $
DATE PAID �— / 7• c
/ /
UNOBSTRUCTED AREA
STORMWATER RUNOFF
ALARMS
MAINTENANCE AGREEMENT
BUILDING AREA
PLUMBING FIXTURES
FINAL SITE GRADING c4�
CONTRACTOR Of (- \.f *-'\
OTHER
/ /
CPHU DATE: — �
CPHU DATE: -� �''
Page 2 0