DRAINFIELDDate 3/30/94 Job Address 1213 NE 94 STREET
Legal Description )at Z f 3 1 ' lam rie.S Rol )
Owner / Lessee / Tenant MOFFLY
Owner's Address 1213 NE 94 STREET
Qualifier DENNIS NEVILLE
S ignature of owner and /or Condo President
Date:
My Commission Expres;
** * '* ::: * ...
FEES: PERMIT N' RADON
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
and/
r Condo President
SS#
Phone 751-7676
State # 0258368 Municipal
# Competency # 12842 Ins.Co. TRAVELLERS
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION INSTALL DRAINFIELD
Square Ft. 400 SQ FT Estimated Cost(value) $1000.00
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO
SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND
TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR
NOTICE OF COMMENCEMENT).
Application is hereby made to obtain a permit to do work and installation as indicated above, and
on the attached addendum (if applicable). I certify that all work will be performed to meet the
standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will
be done in compliance with all applicable laws regulating co ru.tion a ' • ng. ermore, I
authorize the above -named contractor to do the work stated
Si: . ure o
Da e:
N ar as to Con
My mmjson -, -Ex
*
ractor or Owner- Builder
Owner- Builder
* *
N
C.C.F. NOTARY TOTAL DUE ' M'0 ( "'
Fire Other
Engineerinp,
*
**
Electrical
,• i v
APPLICATION FOR:
[ ] New System
[ ] Repair
APPLICANT:
AGENT:
MAILING ADDRESS:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
BLOCK:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
1
2
3
4
APPLICANT'S SIGNATURE:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
[ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[ ] Abandonment [ ] Other(Specify)
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
SUBDIVISION:
ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ •] PUBLIC
.] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building ,# Persons Business Activity
No Establishment Bedrooms Area Saft Served For Commercial Only
[ ] Garbage Grinders /Disposals _[ ] Spas /Hot Tubs [ ] Floor /Equipment Drains
[ ] Ultra -low Volume Flush Toilets
J bther (Specify)
r' 1
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001-4015 -1)
•
PERMIT ,, . - f' ' !
DATE PAID 1 ',i • 'i
FEE PAID $
RECEIPT # �` ?
TELEPHONE:
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
DATE: --
Page 1 of 3
I
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTIOM PERMIT
Permit Application Number `VA- l _W
Scale: Each block represents 5 feet and 1 inch = 50 feet.
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Site Plan submitted by:
PART II - SITE PLAN
/ - L SIGNATURE
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
_ lStnrrk_l.,_imher t 44. 002. 4015 - R1
Plan Approved Not Approved
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ALL C NGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
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TITLE
Date
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Notes +�. -�... �� t r _ -._ , _.
% - County Public Unit
Page 2 of 3
CONSTRUCTION PERMIT FOR:
[ ] New System
[ •] Repair
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
T
A
N
K
D
R
A
I
N
F
I
E
L
D
0
T
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R
FILL REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: 3 /3 0/'1
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
SYSTEM DESIGN AND SPECIFICATIONS
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM
BOTTOM OF DRAINFIELD TO BE [
( ] Existing System ( ] Holding Tank [ ] Temporary /Experimental
[ ] Abandonment [ ] Other(Specify)
• 1 •i
BLOCK: SUBDIVISION:
] INCHES
2
I /4
SITE [ h///+
/]/]
a
HRS Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
PERMIT # r 7 4 / ,k1
DATE PAID J - z ; - 74
FEE PAID $ 4 , 1.)• +i U
RECEIPT # 4 7 7 7
AGENT: xi 6 4if L ! =• e
[SECT ION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6, FA
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMIT
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS 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. SUC.
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
[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 GALLONS
GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE ( ] PER 24 HRS NO. OF PUMPS:
[ •4 , SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ — ] SQUARE FEET SYSTEM
TYPE SYSTEM: [`'] STANDARD [ ] FILLED ( ] MOUND [ ]
CONFIGURATION: [ ] TRENCH [1 BED [ ]
(INCHES /FT]
[INCHES /FT]
[ABOVE /BELOW] BENCHMARK /REFERENCE POIN
[ABOVE /BELOW] BENCHMARK /REFERENCE POIN
EXCAVATION REQUIRED: [ ` ] INCHES
' ,),, 0.1 1) re% // %, /, -
TITLE:
TITLE:
CPH
EXPIRATION DATE: 0/3
Page 1 of
Scale: Each block represents 5 feet and 1 inch = 50 feet.
T -
Notes:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTIOAl. PERMIT
Permit Application Number (75/,‘,. f ()&'V
Tr 5.37TI
Site Plan submitted by
PART II - SITE PLAN
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SIGNATURE
`_ '
Plan Approved Not Approved
1
By i i ail C. ./ J �a c- ; „1„.
• ALL C NGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
TITLE
L 1 -,rt t Jy
"- - --T-r -
Date 3
County Public Unit
1
2
3
4
APPLICANT:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
S 17.
APPLICANT'S` SIGNATURE
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
APPLICATION FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
C <;t] Repair [ J Abandonment [ ] Other(Specify)
AGENT:
DAM SEPTIC TA;NIK
MAILING ADDRESS:
Of) N'•' 111 ST77 , :.,� 1.:rI 3315
TO BE COMPLETED BY.APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [ F.LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
BLOCK:
•
SUBDIVISION:
ACRES [Sgft /43560] PROI ?ERTY WATER SUPPLY: [ ] PRIVATE [Tx] PUBLIC
PROPERTY STREET ADDRESS:'.
( RE
[ ] Garbage Grinders /Disposals
[ ] Ultra -low Volume Flush._
No. of Building # Persons
Bedrooms Area Soft Served
4 REDr�
.Jill lTnO ;
MRS-11 Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 -001- 4015 -1)
Space /Hot Tubs
PERMIT I 9 y�+ ite. (/
DATE PAID c l tf
FEE PAID $ 4. 4 0- 0!/6
RECEIPT f 9 1 2 7
TELEPHONE:
[ ] COMMERCIAL
756 -
75 -3375
DATE OF
SUBDIVISION.
[Section /Township /Range /Parcel No.] ZONING:
Business Activity
For Commercial Only
[ ] Floor /Equipment Drains
thor (Specify)
DATE: 3 -30 -94
Page 1 of 3
A
CONSTRUCTION PERMIT Fek :
[ X ]New System [ ]Existing System
[ ]Repair [ ]Abandonment
APPLICANT: Hernandez, Orlando
PROPERTY STREET ADDRESS: 1213 NE 94 St Miami FL 33138
LOT: 2 BLOCK: N/A
, STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
PROPERTY ID #: 11- 3205 -010 -0020
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1050 ]Gallons SEPTIC TANK MULTI- CHAMBERED /IN SERIES: [Y ]
A [ 0 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS [ 0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
D [ 571 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ Y ]STANDARD [ N ]FILLED
I CONFIGURATION: [ N ]TRENCH [ Y ]BED
N
F LOCATION TO BENCHMARK: CL NE 94 St., 7.61' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 1.1 ] [ INCHES ] [ ABOVE BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 28.9 ] [ INCHES ] [ BELOW BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 72.0 ] INCHES
OTHER REMARKS:
*Install a 1050 gl. C -2 septic tank with its approved outlet iltat.
*Install 571 sq.ft. of drainfield.
*Invert elevation to be no less than 5.70' NGVD.
*Bottom elevation to be no less than 5.20' NGVD.
*Install 42" of slightly limited soil under bottom of drain ,
Perimeter of excavation area shall be at least 2 ft. wider
longer than the proposed absorption bed or drain trench.`,";',
The licensed contractor installing the system is responsible ° tot insiafling the minimum
category of tank in accordance with section 64E- 6.013(3)(f) F.A.C.
SPECIFICATIONS BY: Icaza, Carlos
APPROVED BY: (
DATE ISSUED:
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0) (ostds_cons_4016 - 1]
[ ]Holding Tank [ ] Innovative Other
[ ] Temporary [ NA ]
AGENT: SA0990924, Suarez Guillermo
SUBDIVISION: Miami Shores Bay Vie
[Section /Township /Range /Parcel No.]
[OR TAX II) NUMBER]
CENTRAX #: 13 -SG -19296
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 04 -0265- -N
[ N ]MOUND [ N ]
[ N ]
TITLE: o� 02/o6 /car
'ITLE : Engineer 4 Dade CHD
EXPIRATION DATE : D3LO /`Q.6
Page 1 of 2
, STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Hernandez, Orlando
AGENT: Guillermo Suarez, A- LEAGUE SA0990924
LOT:
BLOCK: N/A SUBDIVISION: Miami Shores Bay Vie ID #: 11- 3205 - 010 -0020
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S
MUST PROVTDE REGISTRATION NUMBER AND STGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE AT
PROPERTY SIZE CONFORMS TO SITE PLAN:[X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.21 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [64E -6, TABLE 1]
AUTHORIZED SEWAGE FLOW: 525 GALLONS PER DAY [1500GPD /ACRE OR 2500GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1560 SQFT UNOBSTRUCTED AREA REQUIRED: 1143 SQFT
BENCHMARK /REFERENCE POINT LOCATION: CL NE 94 St., 7.61' NGVD.
OSTDSNBR : 04- 0265 -N
SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO 10 YEAR FLOODING? [ ]YES [ X ]NO
10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD SITE ELEVATION: 8 FT NGVD
SITE EVALUATED BY: GUILLERMO SUAREZ,
CENTRAX #: 13 -SG -19296
ELEVATION OF PROPOSED SYSTEM SITE IS 1.08 [ INCHES ] [ ABOVE ]BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: N/A FT DITCHES /SWALES: N/A FT NORMALLY WET? [ ]YES [ X ]NO
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: N/A FT NON - POTABLE: N/A FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINE;: 5 FT POTABLE WATER LINES: 62 FT
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture Depth
to
1nYR -1/1 -fl RN Rang n to 6
1 nYR -4/2 -fl n RN nnl i ti r Liman 6 to 72
to
to
to
to
to
USDA SOIL SERIES: 15 Urban land
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
to
1nYP_1 /1 -n RN Rand n to F
1nYR -4/2 -fl (; RN Anlitir• T.imAR 6 to
to
to
to
to
to
USDA SOIL SERIES: 15 Urban land
OBSERVED WATER TABLE56.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [PERCHED
ESTIMATED WET SEASON WATER TABLE ELEVATION:56.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING Replacersent /0.70 DEPTH OF EXCAVATION:72.0 INCHES
DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
Soil replacement required - See attached sheet.
DATE: 1/27/04
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1) (ostds eval 4015 -3] Page 3 of 3
APPLICANT:
STATE OF FLORIDA
tDEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
" SITE EVALUATION AND SYSTEM SPECIFICATIONS
PROPERTY ID #:#.
>
BLOCK:
si ' ar��.
SUBDIVISION:
a 00 •yPat) /' e)
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE
SURFACE WATER: � FT DITCHES /SWALES:
WELLS: PUBLIC: uidd FT LIMITED USE: w 4:- FT
BUILDING FOUNDATIONS: FT PROPERTY LINES:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES 0 NO
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color
USDA SOIL SERIES:
Textu6e
f
Depth
f; to
to
, , r6 . ,tf iv.: • V to
to
__4 to
''to
'6777-4. t o 77 ----
SITE EVALUATED BY: r
OH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3J which may be used)
(Stock Number: 5744- 003 - 4015 -1)
ey0
AGENT:
„e° dl
[Section /Township /Range /Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFOiMS TO SITE PLAN: [" ] YES [ ] NO NET USABLE AREA AVAILABLE: . � ACRES
TOTAL ESTIMATED SEWAGE FLOW: ,e ' GALLONS PER DAY O �
ESIDE L OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: .I GALLONS PER DAY [1500 GPD /ACRE OR 2500GPD /ACRE
UNOBSTRUCTED AREA AVAILABLE: �_ ' ;= SQFT UNOBSTRUCTED AREA REQUIRED: if- SQFT
BENCHMARK /REFERENCE POINT LOCATION: 9o4 i 4. �. :)' ("�eyc g e t " e. e, ',r - .
ELEVATION OF PROPOSED SYSTEM SITE IS C J [fINCHE) FT] (ABOVE BELOWrEENCHMARK REFERENCE POINT
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
104Y • FT NORMALLY WET? [ ] YES ,p1 NO
PRIVATE: 4//2 a FT NON-POTABLE: /J 1 FT
FT / POTABLE WATER LINES: g FT
10 YEAR FLOODING? [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: Aim , FT MSL /NGVD SITE ELEVATION: 10 FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell #(Coolor Textures_ Depth
/0V/1 i �yfA feo �1� to
ci O. (4.
I a "a
USDA SOIL SERIES: / ' '6a8
OBSERVED WATER TABLE: ,',2 / / INCHES [ABOVE / BELOW) EXISTING GRADE. TYPE: (PERCHED/ APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: .w f ( INCHES [ ABOVE / `iELO EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [V] NO MOTTLING: [ ] YES [ ] NO DEPTH: 4%/i INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION:, INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [X] BED [ ] OTHER (SPECIFY)
REMARI(S /ADBITIONAL CRITERIA:
'7i- ') (
Ni
PERMIT # l'
to
0
), i �u 01 ! d&A t0
I
_iGs.3 P( f/ia-;1's? _(
DATE:
to
to
-
to
Page 3 of 3
INSTRUCTIONS: '•
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: 'Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record the estimated sewage flow for the establishment from Table I (residence) or Table 2 (non - residential),
Chapter 10D-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ + 1 SHOT H.I. H.I. H.I.
H.I. [ -1 SHOT [ -1 SHOT [ - ISHOT