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By
Site Plan Submitted by
Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number / , -
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HRS-H Form 4015, Feb 85 (Obsdetes previous editions which may not be used)
(Stock Number 5744-002-4015-6)
PART II SITE PLAN
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SIGNATURE TITLE ,/
Not Approved Date ,//'
County Public Unit
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ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
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Page 2 of 3
CONSTRUCTION PERMIT FOR:
New System [ E`xistin System
] Repair [ /1 Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
T
A
N
K
0
T
H
E
R
[
[
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK:
SYSTEM DESIGN AND SPECIFICATIONS
APPROVED BY:
[�
',Holding Tank [ 7 � J Temporary /Experimental
[ j Other(Specify)
SUBDIVISION:
D [� ".>� ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND
I CONFIGURATION: [ ] TRENCH [ ] BED [ ]
F LOCATION OF BENCHMARK: ? G8 / ;; \ °
I ELEVATION OF PROPOSED SYSTEM
E BOTTOM OF DRAINFIELD TO BE [
L
/,
D FILL REQUIRED: [ } INCHES EXCAVATION REQUIRED: [ z- =] INCHES
/
SITE [
d
SPECIFICATIONS BY: TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0)
AGENT: j /
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[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. HRS 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.
',?7.< [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: [ ]
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
],[INCHES /FT] [ABOVE /BELOW]BENCHMAR1 /REFERENCE POINT
EXPIRATION DATE:
CPHU
Page 1 of 2
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