709 NE 93 St (7)JOB:
BUILDING
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ELECTRICAL : • •
PLUMBING .. WORK
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DONE BY: �j
: : REQUESTED
Inspector's Report:
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The following is roody for Inspection:
AD:
: WILL BE READY
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Cp
CC:.`STR ucTION PERMIT 'r'OR:
[ Nut, Sytem [ ; Existing System
[ Repair [ Abandonment
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
ETF'I::. CF
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
( ::.a.pter '' FS
SYSTEM DESIGN AND SPECIFICATIONS
DH 4016, 10196 (Replaces HRS -H Form 4016 (page 1) which may be used)
(Stock Number: 5744- 001 - 4016 -0)
[
[
AFPL I CANT : AGENT:
BLOCK: S:;BDIVISION:
Rrt.er 1GD -6. YAC
"r'EFSRTT
DAME PAID
FEE PAID $
RECEIPT #
Holding Tank Temporary /Experimental
Other(Specify)
:F.YICTION /TOWNSHIP /RANGE /PARCEL NUMBER]
TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -G,
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. DEPARTMENT OF HEALTH 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.
T ; ] [GALLONS / GPD] SEPTIC TANK /AEROBIC 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 PER DOSE DOSING TANK CAPACITY DOSE KATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ j STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: ] TRENCH [ ] BED [
N
F LOCATION OF BENCHMARK:
1 ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
✓ :BOTTOM OF DRAINFIELD TO BE f 1 [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 'INCHES EXCAVATION REQUIRED: ' ] INCHES
SPECIFICATIONS BY: TITLE:
APPROVED BY: TITLE: CHD
DATE ISSUED: EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICATION 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.
TANK: Minimum specifications from Chapter 10D -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -6, FAC.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID #: 27 character ID number for property. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
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 personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.