1045 NE 97 St (14)STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYST
CONSTRUCTION PERMIT
Authority: Chapter 381, FS
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System
[ ] Repair [ J Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
BLOCK: SUBDIVISION:
-- [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6,
FAC. REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER
PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. DEPARTMENT OF HEALTH 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. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFICATIONS
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SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
] [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 KATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
[ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [ ] TRENCH [ ] BED [ ]
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
FILL REQUIRED: [
J INCHES
DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1] which may be used)
(Stock Number: 5744- 001 - 4016 -0)
EM
i Chapter 10D -6, FAC
] Holding Tank [ ] Temporary /Experimental
J Other(Specify)
AGENT:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
] [INCHES /FTJ [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED INCHES
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
•
4 4A4.&
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TITLE: CHD
EXPIRATION DATE:
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INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICATION FOR: Check type of permit; if "Other" specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY 1D #: 27 character ID number for property. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 10D -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -6, FAC.
OTHER: Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the
date issued.
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Scale: Each block represents 5 feet and 1 inch = 50 feet.
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Notes:
Site Plan submitted by:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN
HRS -H Form 4015, Feb 85 (Obsotetes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015 -6)
SIGNATURE
Plan Approved Not Approved
B
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
TITLE
Date
County Public Unit
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