419 NE 94 St (8)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applic nt L ac \" P it Number V 7 00.5
'4/ `j N 6 "/ s cw/ PART I1 - SYSTEM INSTAL TI INSPECTION AND FI CLIs
L IN TAL
S � f
Installer ' " 'A 7f1 L 4l Tank Manufacturer
Proper tank legend: Yes No /-1- Tank material � .1/4./ crank level: Yes No____
Tanks watertight: Yes ✓ No P Tank size � (e� gallons gallons gallons
Propr tank outlet device: Yes /No
Dralnfield Trench
Lengths Width kgngth Width
feet feet ` feet feet
feet feet INI feet feet
feet feet 4 feet feet
Total = ft / Total = ft
Systems located as permitted: Yes No / /A
Systems including plumbing stub -outs installed at proper elevation: Yes No A..
Average depth to drainpipe invert from finished grade: inches Maximum depth Inches
Average depth of drainfield gravel: u inches
Proper gravel size: Yes ✓ No
Backfill or fill material as required: (Quality) Yes No
Other findings f /.4 f ic
Inspected by:
Date — 27- Si proved by:
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744- 002 - 4016 -4)
Manhole or marker to grade: Yes No
Absorption Bed
Length 2 f eet x` feet= ft
Length feetx feet= ft
Proper No. drainlines: Yes /No
14tr'
Proper pipe separation: Yes No
Distribution box level: Yes No
Minimum depth of gravel 10
Gravel is suitable quality: Yes ir o
(Quantity) Yes No
Date -- Z —87
A
PART 1I1 >Pfl L INSTA LA ON APPROVAL
' I 12 DdDe
COUNTY PUBLIC HEALTH UNIT
ES OT GUA NT E� FORMANCE
AN APPROVED INSTALLATION D
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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