1146 NE 97 St (6)CONSTRUCTION PERMIT FOR:
['.] New System [ ] Existing System
[ ] Repair [ ) Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
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
T [
A [
N [
K [
D [ J SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ) SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED
I CONFIGURATION: [ ] TRENCH [' "] BED
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ [INCHES /PT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: ( ) INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS
BLOCK: - SUBDIVISION:
[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.RATE [ ] PER 24 HRS NO. OF PUMPS: [ )
DH 4016. 10/96 (Replaces HRS -H Form 4016 [page 11 which may be used)
(Stock Number: 5744 - 001 - 4016 -0)
c , 1.D -6 , FAC
] Holding Tank [ J Temporary /Experimental
] Other(Specify)
AGENT:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
TITLE:
MOUND [ ]
TITLE: CHD
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
�.� 4-4 c
EXPIRATION DATE:
Page 1 of 2
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 ID #: 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 1OD -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.
APPLICATION FOR:
[ J New System
[;%] Repair
APPLICANT:
AGENT:
MAILING ADDRESS:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
1
2
3
4
•
1'
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
APPLICATION FOR CONSTRUCTION PERMIT RECEIPT #,9
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
•
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: ; SUBDIVISION: i L /! , ,;, ` 1.\ DATE OF
(i SUBDIVISION:
PROPERTY ID #: / ; [Section /Township /Range /Parcel No.] ZONING:
PROPERTY SIZE: - 2( ACRE [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [±!] PUBLIC
/
BUILDING INFORMATION [I] RESIDENTIAL [ J COMMERCIAL
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Soft Served For Commercial Only
[ ] Garbage Grinders /Disposals [ ] Sp/s /Hot Tub's [ ] Floor /Equipment Drains
[ ] Ultra -low Volume Flush Toilets [ ] Other (Specify)
APPLICANT'S SIGNATURE: DATE:
DH 4015, 10/96 (Replaces HRS -H Form 4015 ]Page 1] which may be used),
(Stock Number: 5744- 001 - 4015 -1)
] Existing System [ ] Holding Tank [ ] Temporary /Experimental
] Abandonment [ ] Other(Specify)
•
j
C.; /
>
ir
TELEPHONE:
Page 1 of 3
:bee: type of p if type in
. OV/TN.7':3 full name.
T'cleni.one foy
?top,: - ty 01711;:r'r,
o:ntrcet, ci:y, cc .f:f; (1•:.?::.C2.1"2. 07
Cite. or public.
Stn., ror oropeci■i. 'Tx wititout ctsi:reti t.lroct CC: 7. ..1.
:o lot: or c.".ti.,ch. /01;;LZICIL.
rcetitlenti.:1 r eurnm.
1,01, nnri fo: (. OF 12/717:',•cord(o r; LoOclivition). !et in 1'.)1 co 10:
'cLitt c::
0: SJ70VsON 071H! etite : :biv:on cconty plat boo's.: .f...ct.e
:". ",;:e
- 011: 27 cl...:rt number tor pioperty. Departnient cr dy require property tippriti:-er I OP' or soc(i011,i0v,n,,iiipiran ;poret.1
N2i I 7.:31C C.L•i:0 of
becin IC3 1 c 1 C7 071
.or- 0071 1' 7.2.7.'/r;i:I.
in cl...let■ietirty,
Liet of hie
CIOCiCr'1, 011
Cot nt rot)1, far - :/rovidn
Hu: 1; f0):1e or 0 LP 7.;C C.:;;;.• 0.•
eo..10:: 0.
11 .7 !..7:!,,,:■111 Or 0.C%
1[1,0
ttpolietnion: ; . .
1.7.1ter
'N if ;to: ,Tri'.icnbin.
tore or applicant or :'.nt. n.pplication on dtt. 1' ;:ealth ,:ppro71
A 0.74` :! F 'r
■411
ci f5".2- itTt cp":nr
well within 2.C3 fet.t. :5 1::,
. • . 0 "ADO.' ? :::;.C.ecn L. . . -
0 nom: Lit0v.i02 uf the
neces:::::ry to ectt:i-nnine cornponition cuttntity
APPLICANT:
LOT: L�
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
PROPERTY ID #:
/g
THE MINIMUM SETBACK WHICH
SURFACE WATER: 99 ° ° '' ) FT
WELLS: PUBLIC: Gfh FT
BUILDING FOUNDATIONS:
SITE EVALUATED BYt _ -_
BLOCK:
v� l
° J , 1G
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
10 YEAR FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE 1 �"
Munsell #/Color Texture Depth
7i? , " to
f i !; , U � , to —
to
to
USDA SOIL SERIES: i %/12 !�• 9
to
to
to
to
to
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3] which may be used)
(Stock Number: 5744 -003- 4015 -1)
PERMIT #
1 ( ,/, ',7 /7
G AGENT: ; h / .,
SUBDIVISION:
// c
[Section /Township /Range /Parcel No. or Tax
, ,■„, : J)
ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ] NO NET USABLE AREA AVAILABLE: ‘'"%/) ACRES
TOTAL ESTIMATED SEWAGE FLOW: ) GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2)
AUTHORIZED SEWAGE FLOW: >>�';� GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: <-'j SQFT UNOBSTRUCTED AREA REQUIRED: 47.'% SQFT
" [ INCHES /F'TJ' [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
DITCHES /SWALES: /(1' FT NORMALLY WET? [ ] YES [`J NO
LIMITED USE: ��OG FT PRIVATE: FT NON - POTABLE: ,; –. — FT
(;? FT PROPERTY LINES: /;° FT POTABLE WATER LINES: == FT
A
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [4 NO
FT MSL /NGVD SITE ELEVATION: /i' FT MSL /NGVD
10 YEAR FLOODING? [ ] YES [1: -NO
SOIL PROFILE INFORMATION SITE 2
Munsell # / Color Texture Depth
g° //� to
to
to
to
to
to
to
to
to
USDA USDA SOIL SERIES: (/ /
OBSERVED WATER TABLE: G / /✓ !NCHESj [ABOVE / BELOW] EXISTING - GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TALE ' l'L - .INCHES ABOVE /BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [,]INO MOTTLING: [ ] YES [<Y NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: O % DEPTH OF EXCAVATION: ,> INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [-)'BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential),
Chapter 10D -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter 1OD -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be treasured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. [ - ] SHOT [ - ] SHOT [ - ] SHOT
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents i0 feet and 1 inch = 40 feet.
Notes:
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744 -002 -4015 -6)
Not Approved
PART II - SITEPLAN
Site Plan submitted by:
Plan Approved
By County Health Department
Date
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 4