260 NE 95 St (4)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
P i umber 7s 2 eD
PART III S STE NS ALL1TION 6 PECTION AND FINAL IN42_ T N APPROVAL
O RO AL
Installer CI /4 i 1 ∎./ Tank Manufacturer WM.
Applicant Al Cl/J
Proper tank legend: Yes
Tar°k3 watertight: Yes_V No
Prcper tank outlet device: Yes' No
Drainfield Trench
Lnngth Width Length
feet feet / feet
feet feet N feet
feet feet feet
Iota; = ft /
s4
a verage depth of drainfield gravel: 3 inches
Inspected by: 6: / I9
Date 8 l7Approved by
No Al /4
Tank material i _ ®!L e/Z.C7 Tank level: Yes
Tank size
//4 gallons
Length 3
Width
feet Length
feet Proper No.
feet Proper pipe
Total = ft Distribution
Systems located as permitted: Yes No _A
Systems including plumbing stub -outs installed at proper elevation: Yes No /VA
Average depth to drainpipe invert from finished grade inches Maximum depth•2b Inches
� 1/
Minimum depth of gravel , inches
Toper gravel size: Yes ✓ No Gravel is suitable quality: Yes ✓ No
Eackfill or fill material as required: (Quality) Yes No (Quantity) Yes s/ No
Other findings findings - Z7DA / / 2 ( t / Zell
,Aezi f /e •
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744-002- 4016 -4)
PART III - FINAL INSTALLATION APPROVAL
feet x feet=
No -
gallons gallons
Manhole or marker to grade: Yes No -- 4
Absorption Bed
/
feet x /` feet=
5, COUNTY PUBLIC HEALTH UNIT
AN APPROVED INSTALLA 10 DOE . •T GUARANTEE P FORMANCE
des: ✓ No
4�
separation: rainlin Yes Yes / No
box level: Yes No ���
Date 3 -Z5- b7
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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