SEPTICSTATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant 4.2P/A4 4-; -S rP �t S Permit Number V-C36-3 . f o 3 3 t j 9 s 6T' fJ a<I rr �+ J F
PART II - SYSTEM INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL-
Installer 444 /.1-; 6 y 3 TZ NA S, Tank Manufacturer
Proper tank legend: Yes No Tank material Tank level: Yes No
Tanks watertight: Yes No Tank size gallons gallons gallons
Proper tank outlet device: Yes No Manhole or marker to grade: Yes No
Drainfield Trench Absorption Bed
Length Width Length Width LengthA feetx A' feet = 4 64) ft
feet feet feet feet Length feet x feet= ft
feet feet feet feet Proper No. drainlines: Yes No
feet feet feet feet Proper pipe separation: Yes No
Total = ft Total = ft Distribution box level: Yes No
Systems located as permitted: Yes ✓ No __
Systems including plumbing stub -outs installed at proper elevation: Yes No
Average depth to drainpipe invert from finished grade: / 7 inches
Average depth of drainfield gravel: / 4 inches Minimum depth of gravel inches
Proper gravel size: Yes No Gravel is suitable quality: Yes V No
Backfill or fill material as required: (Quality) Yes _ No (Quantity) Yes —t . No
Other findings:
Inspected by: £ .L .3EY1 d
c4) (6 Date 7// VAT
Date Approved by
PART III N L IICVST / TION APPROVAL-
Maximum depth 0-1 Inches
;k„oliz_
AN APPROVED INSTALLATION DOES NOT GUARANTEE PERFORMANCE
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4016 -0)
COUNTY PUBLIC HEALTH UNIT
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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