1285 NE 94 St (7)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant .l'T • foulus P e mit Number
et- os77
pO a 74/ PART II SYSTEM INSTALLATION INSPECTION AND Fl AL INSTA LATIOAPPROVAL
Installer Slid (90 /c/
Propertank legend: Yes
Tanks watertight: Yes
Proper tank outlet device: Yes No Manhole or marker to grade: Yes ' No
Absorption Bed
Length width Length Width Length a7 feet x 8• feet = 3
_00
feet feet feet feet Length S,'� feet x5 feet = ft
feet feet feet feet Proper No. drainlines: Yes ✓ No
feet feet feet feet Proper pipe separation: Yes V No (,�
Total = ft Total = ft Distribution box level: Yes L/H No
Inspected by:
Date
Approved by
Drainfield Trench
AVA
Systems located as permitted: Yes 1/ No
Systems including plumbing stub -outs installed at proper elevation: Yes
Average depth to drainpipe invert from finished grade: J inches Maximum depth. 2 7` Inches
Average depth of drainfield gravel: 15 inches Minimum depth of gravel: /c2 inches
Proper gravel size: Yes ✓ No Gravel i suitable quality: Yes �No
Backfill or fill material as required: (Quality) Yes No (Quantity) o e eq ed (O a y) a (Q y) Yes
PART III - FINAL
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4016 -0)
Tank Manufacturer
Tank material Cdnc - , (vi- Tank level: Yes
Tank size
gallons
TIO PPROVAL
A//4-
gallons gallons
Date
AN APPROVED INSTALLATION DOES NOT GUARANTEE PERFORMANCE
v/ No
COUNTY PU LIC HEALTH UNIT
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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APPLICANT:
/.
PROPERTY STREET ADDRESS:
LOT: / BLOCK:
PROPERTY ID • # '
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH
DRAINFIELD INSTALLATION y�
.( ] [09] AREA [ 1 ]� AT ' ( 2 1 3 7 e e"§QFT
T J ,.[10]- DISTRIBUTION BOX /HEADER
[;_] [11] NUMBER OF DRAINLINES
X1. (12] DRAINLINE SEPARATION 3 e'
[ ] [13) DRAINLINE SLOPE
[ ] [14] DEPTH OF COVER / "
[ ] [15] SYSTEM ELEVATION 7 , -2(7
[ 1 [16] SYSTEM LOCATION__
[ ] [17] DOSING PUMPS
'( J [ 18J AGGREGATE SIZE
[ ] [19] AGGREGATE SOURCE
[ ] (20] AGGREGATE WASHED
( ] [21] AGGREGATE DEPTH '1,4
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Authority: Chapter 381, FS & Chapter 10D -6,
TANK INSTALLATION (p. •
[01] TANK SIZE [1]7(7) - (2]
[02] TANK MATERIAL C�� 2 '1
[03] OUTLET DEVICE U
(04] MULTI- CHAMBERS a -s-
[05] LEGEND Al yam,
[06] WATERTIG - s2-2- -
(071 LEVEL /),/
[08] DEPTH 0 LID
FILL /EXCAVATION MATERIAL
[22] FILL AMOUNT
[23] FILL TEXTURE
[241 EXCAVATION DEPTH
(25] EXCAVATION AREA 4.2
(26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS:
[
(
[ l
[ ]
DEEA ' TMENT E
-: SUBDIVISION:
=`
rL
Z
CONSTRUCTION [APPROVED /DISAPPROVED]:
FINAL SYSTEM [APPROVED /DISAPPROVED]:;
• /
•
AGENT:
[ SECTION /TOWNSHIP /.RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
HRS - Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
FAC
PERMIT 1
RECEIPT #
FEE PAID
DATE PAID
SETBACKS j
[27] SURFACE WATER '/moo
(28] DITCHESN /rte -
[ 29 ] PRIVATE WELLS
(30 ] PUBLIC WELLS ^�
[31] IRRIGATION WELLS �--v--
[32] POTABLE WATER LINES /Q
[33] BUILDING FOUNDATION 1 .7
[34] PROPERTY LINES 5
(35] OTHER
FILLED /MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION MATERIAL
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
(41] STORMWATER RUNOFF 4 7
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[441 BUILDING AREA
(45] PLUMBING FIXTURES
[46] FINAL SITE GRADING
[47] CONTRACTOR. -- -
(48] OTHER
f
/
ABANDONMENT
(49] TANK PUMPED /Z/ .Z /
(50 ] TANK CRUSHED AND FILLED - 0//,41..
c� 7 CPHU DATE :L..2-„4 -�
CPHU DATE/ %_ 2 - /
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