500 NE 97 St (12)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PE(RUT
Permit Application Number idu
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes:
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PART II - SITE PLAN
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Site Plan submitted by: - r fr %''
SIGNATURE T11E,
Plan Approved Not Approved Date
By � County Public Unit
ALL CHANGES MUST BE APPROVED, BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used) Page 2 of 3
(Stock Number. 5744.002- 4015.6)
LOT:
PROPERTY ID #:
THE MINIMUM SETBACK WHICH
SURFACE WATER: FT
- WELLS: PUBLIC: FT
BUILDING FOUNDATIONS:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
PROPERTY SIZE CONFORMS TO SITE PLAN: [
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
SOIL PROFILE INFORMATION SITE 1
CAN BE MAINTAINED FROM THE
DITCHES /SWALES:
LIMITED USE: - FT
FT PROPERTY LINES:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [`] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
SITE EVALUATED BY:
AGENT:
PERMIT #
[Section /Township /Range /Parcel No. or Tax 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.
YES [ ] NO NET USABLE AREA AVAILABLE: ' ACRES
GALLONS PER DAY (RESIDENCES -TABLE 1 / OTHE -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
PROPOSED SYSTEM TO THE FOLLOWING FEATURE$:
FT NORMALLY WET? [ ] YES [4
PRIVATE: FT NON - POTABLE: FT
<- FT POTABLE WATER LINES: FT
10 YEAR FLOODING? [ ] YES ['"J NO
SITE ELEVATION: FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE :_,(PgRCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION,: INCHES [ ABOVE - ELOW )] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [ NO MOTTLING: [ ] YES [' NO DEPTH: INCHES
DEPTH OF EXCAVATION: ' "� INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH ( ] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) Page 3 of 3
(Stock Number: 5744- 003 - 4015 -1)
ENSTRUCTIONS:
PERMIT C: Permit tracking number assigned by CP:EU.
APPLICANT: Property owner's full name.
AC ENT: Property owner's legally authorix.ed rey,cLo:active.
;31I,OCIt, SUDDIVISION: Lot, block, and subdivision for lei.
:::::1OPERTI! EDO: 27 character number for property. (prope.;,:y appmiser .TD I/
tar
7. SIZE: Check if prepeity size ct Lite cortIO:ms anbralttcs: site ;.T:
Li' paved areal
normally wet drainage ditches, ilia:rles, or Cfae.' zf r
:;ii:
MINIMUM SE:TRACKS:
Record the estimated sewage flow :cc - c t:riablishaneri fror.n
10D-6, :FAC. 'accord the ruthor: e.esl 20 fon :'7;) :: • -
per day per acre for pi,ivato wcte ^,1:E cc.d 25C0
does rot equr." or exceed the esti: the 7:rai
Record the sc.ua.: of . ried cr,:n -
times as large as the drainfield orpii_on ansI 75; Zq. _
setbacks in Cliapter 10D-6, ;PAC. - 11 - lie unobstructed crec b.:. dra'-oeld.
:3ENCILIMARK INFORMATION: Record the location of the benchmark. If using c surveyor's hena':mark reco:d the actual elevation. :Zr,ccrei tbe
elevation of the proposed system in relation (above or below) - o tIc
Record minimum setbacks which can be mire: to all listed fectares. Aclucl aneasun;menin, roust be recorded or "NA"
for non applicable features. Feet on site plan or within 75 fc:.: of the lei must be measured. °I
of any public drinking well within 200 feet of the app/icant's lot crt also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject flooding record 10 year flood elevation for clic: r
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed chcorr,tion crec to n minim - r: deth of S feet on refuaal errs Sc".
identification will use USDA Soil Classification meth (M:lsell colors: and USDA soil teutt:ron). acfun,nIn
be clearly documented. Provide USDA soil series if available, r‘: :ord 'UN,"' if the series cannot be determined-
WATER TABLE: Record the depth of the observed water table at the time of the ev 1`.. "perched" or nr.pparant" rn
appropriate. Record the estimated wet season water table clevatir ba.aed or rite cvalaction, USDA coil seer,
historical information. Indicate if there Er high VietCr table ve,geii ion Ezene:::. EI'moniir.T, in - nv.c3 r:..
SOIL.. TEXTURE: Record soil texture or /coding rc:rr for system sizing.
O.F EXCAVATION: If applicable record depth of enrs:va res!,uirad. accord 'NA' 7etc.
3RAIN7IELD CONF Check drainfield configuration retluired. 7.f other, specify type.
ADD:TIC can Record any additioml remarks p.:rtir to rite or installatien. f. dosing
SI ;EVALUATED 3Y: Signature of evaluator, title, and rate of evaluation. ProfeLsIons
WORI(S1-. ELEVATION OF / NCI FOINI L:
SITE I SITE 2 SIII 3
:-.:-: SHOT: }.l. FL:. Fri1.11.
H.I. [-] SNOT I SHOT H SIECIIT
APPLICATION FOR:
( ) New System
[ ] Repair
APPLICANT:
AGENT:
MAILING ADDRESS:
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:
PROPERTY ID #:
PROPERTY SIZE:
BLOCK:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
Unit Type of
No Establishment
1
2
3
4
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
[ ] Existing System [ ] Holding Tank
[ ) Abandonment [ _.] Other(Specify)
BUILDING INFORMATION [ J RESIDENTIAL
] Ultra -low Volume Flush Toilets
SUBDIVISION:
ACRES [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
No. of
Bedrooms
Building
Area Sqft
APPLICANT'S SIGNATURE: DATE:
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4015 -1)
[
TELEPHONE:
] COMMERCIAL
PERMIT # '
DATE PAID �7
r ,
FEE PAID $ `, r
RECEIPT #
J Temporary /Experimental
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
# Persons Business Activity
Served For Commercial Only
] Garbage Grinders /Disposals [ J Spas /Hot Tubs [ ] Floor /Equipment Drains
( ,] Other (Specify)
Page 1 of 3
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'crduicinpuoc-.. ,• or . c.:" •- - •
cloy 'crcc included in e.ilculalin., lot
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A..) 2o a : rddress vaitLuut co. ' , :ci• - • i7" .t; • .,C1: . eusoly.
)N3: 3 rov:6 - : detaileci t lot o. .•o
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offieo.
NO. Count rid room:. Cc:CcjorC •••i-ouily . LuCC17:11
;c pfl Is
- 701. S.C.1.11.1ce f u ". c •
zer patio.; Cr it.r.:er; •
Tolu o f crc:cn;: --;cccU'c' ocng, _ : '.'. :crkC'j- :- cc • • "•' • ;' • •
corn • • ;1717,7 : •
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- :uai.clertral.., ;Co:. ; • c." _
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feutures • 1;
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uil.er • ••,'
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•
CONSTRUCTION PERMIT FOR:
[I ] New System [ Existing System [' Holding Tank [ Temporary /Experimental
] Repair [J Abandonment [,/ JOther(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT: BLOCK:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
T [
A [
N [
K [
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.
SYSTEM DESIGN AND SPECIFICATIONS
]ALLO S_J� GPD EPTIC 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: [ ]
FEET,PRIMARY DRAINFIELD
FEET
[ ] STANDARD [
[ ] TRENCH
D [ �]SQUARE
R [ ] SQUARE
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: [ ] INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
X
f
SUBDIVISION:
AGENT:
SYSTEM
SYSTEM
] FILLED
] BED
TITLE:
TITLE: ,
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 - 0)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
[ ] MOUND [
[
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ � ] INCHES
CPHU
EXPIRATION DATE:
Page 1 of 2
;NSTRUC :ONS:
P = .1,bTT NUMBER: Permit tracking number casigned by CPHU.
A:.'P-.ICA`:ION FOR: Check type of permit, if 'Giber° specify type in "s?c '.c.
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 !DO: 27 character id number for property. (CP9.1U may require property cnnrciacr J t1 Cr s ctticn /towntio /range /percel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANX: Minimum specifications from Chapter 101)-6, FAC.
DRA°- NFIELD: Minimum specifications from Chapter 1OD-6, PAC.
OTHER: Other specifications, such as operating permit requirements, low - volume Our' toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered eng: eer must be sealed.
APPROVED BY: County Public Health Unit (CPHU) personnel reviewing and approving perry t.
DATE ISSUED: Date permit is issued by CPHU.
EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for fl stem repairs become void 90 days from the data
issued.