54 NE 95 St (9)Installer
Propertanklegend: Yes
Date
Length
feet
feet
teet
Total =
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant Perrnit Number S'6 cP6 mss`
..1/1/
A T 11 - SYST INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL
,lOPO/1 f
Width
ft 2
Tanks watertight: Yes_,crl No
Proper tank outlet device: Yes No
Drainfield Trench
feet -j
feet
feet
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: _3 / inches Maximum depth
Average depth of drainfield gravel 1 inches Minimum depth of gravel /7- inches
Proper gravel size: Yes j/ No Gravel is suitable quality,: Yes No
Backfill or fill material as required: (Quality) Yes _,i No
Other findings
Inspected by: Z . /
Approved by
No Tank material
AN APPROVE 'INSTALLATION DOES NO' - UARANTEE PERFORMANCE
l
Note: Completed copies of this form will be provided to e applicant, installer and the building department.
HRS—H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4016-0)
Tank Manufacturer
Tank size• rf, gallons
Length Width
feet feet
feet feet
feet feet
Total = ft
.0
Tank level: Yes
gallons
Manhole or marker to grade: Yes No
Absorption Bed
Length / /.73 x feet = 96, 3ft
Length2/ feetx_6 feet =/T ft
- so/
Proper No. drainlines: Yes . No
Proper pipe separation: Yes ✓ No
Distribution box level: Yes, No
(Quantity) Yes ✓ No
3 / Inches
Date /7 V
PAF�fi - FINA INSTALLA II j PPROVAL
COUNTY P BLIC HEALTH UNIT
gallons
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