395 NE 97 St (11)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant r Permit Number t` -
PART 11 ; S Y STEM INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL
2
Installer
Proper tank legend: Yes l No
Tanks watertight: Yes No Tank size: gallons
Proper tank outlet device: Y e s ? ✓t No
Drainfield Trench
Length Width
feet feet
feet feet
feet feet
Total = ft
Tank Manufacturer ! '
Tank material ' ��;. Tank level: Yes 1J / No
gallons
a
Manhole or marker to grade: Yes fdfr No
Absorption Bed
Length Width Length ' feetx i' feet = ' -,d. ft
feet feet Length feet x feet = ft
feet feet Proper No. drainlines: Yes No l )
feet feet Proper pipe separation: Yes 4 -°` No _
Total = ft Distribution box level: Yes No =
Systems located as permitted: Yes ,, Y No
Systems including plumbing stub -outs installed at proper elevation: Yes No
Average depth to drainpipe invert from finished grade '" inches Maximum depth Inches
Average depth of drainfield gravel: s. inches Minimum depth of gravel - inches
Proper gravel size: Yes L No
Backfill or fill material as required: (Quality) Yes No (Quantity) Yes --' No
Other findings:
Inspected by: °_,/ dit'%
Approved by:
Gravel is suitable quality: Yes No
PART III FINAL 1TALLATION APPROVAL
COUN�
HEALTH UNIT
1 ) Date
AN APPROVED INSTAL ION DOES NOT GUARANTEE PERFORMANCE
Note: Completed copies of this form will be\provided to the applicant, installer and the building department.
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744-002-4016-4) Page 2 of 2
gallons