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770 NE 97 St (14)AP LICANT: • PROPERTY STREET ADDRESS: LOT: 1 PROPERTY ID #: SYSTEM DESIGN AND SPE v • L D FILL REQUIRED: 0 T H E R SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL CONSTRUCTION PERMIT J) Authority: Chapter 381,,( & f BLOCK: c f/ • INCHES SUBDIVISION: CONSTRUCTION PERMIT OR: [1J] New System f Existing System [].Holding Tank [J] Temporary /Experimental [e) Repair [4] Abandonment ( Other(Specify) D (5 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [-'] STANDARD [44 FILLED I CONFIGURATION: [6j] TRENCH [ A] BED N r „ pp F LOCATION OF BENCHMARK: Al/ �-� (j' 6 I ELEVATION OF PROPOSED SYSTEM SITE U <2 ] (INCHES / E BOTTOM OF DRAINFIELD TO BE [ 52 _ g 0 ] [ IN HI)S /FT DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1) which may be used) (Stock Number: 5744 -001 - 4016.0) Applicant D -6, FAC AGENT: / - 1 f pu [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. 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. [GALLONS / GPD](S� EPTIC TANK AEROBIC UNIT CAPACITY [GALLONS / GPD] CAPACITY GALLONS GREASE INTERCEPTOR CAPACITY GALLONS PER DOSE DOSING TANK CAPACITY DOSE •RATE [ ] PER 24 HRS NO. OF PUMPS: MULTI- CHAMBERED /IN SERIES:[ ] MULTI- CHAMBERED /IN SERIES:[ ) [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS] 64: [ABOVE /B [ABOVE/ EXCAVATION REQUIRED: [;t0) INCHES f / f MSTAL1 92' t U �1_� RS SAND Uf � ' . _ Z �uY�(�.1_ lJl i ��.znrvr� EFOS1 V' P RF e i1,W1 r. t 4s6 ,.� ; I V T gi FI9A)10419 (81OrrOM OF OPAINFIELD .f L Vag TITLE:, .TITLE: c, 16 CHD 7.NE EMIG TM SHALL BE PUMPED MD SOO PERMIT # O©rl- `=�� 5 DATE PAID 0 -2,_ - FEE PAID $ RECEIPT # a R e, n [ ] MOUND [ G ( 47 BENCHMARK /REFERENCE POINT L3) BENCHMARK /REFERENCE POINT [ ) EXPIRATION DATE: -1 N r� a r� G 1 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 IOD -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. • v n -. i;�' 11:. 1Gf.15 • 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. Pp;LICATION FOR: j New System ] Repair APPLICANT: frin6. S AGENT: MAILING ADDRESS: TO BE COMPLETED BY APPLICANT OR APPLICANT'S AMJ AGENT. ATTACH BUILDING PLAN AND TO -SCALE SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER lOD -6, FLORIDA ADMINISTRATIVE CODE. PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED] Or LOT: 3 B LOCK: 61 SUBDIVISION: ) 1 � \ `� DATE OF 9�Q s /'" SUBDIVISION -6 PROPERTY ID #)9... - . M [Section /Township /Range /Parcel No.] ZONING: PROPERTY SIZE:A / 9 ACRES [Sqf 43560 PROPERTY WATER SUPPLY: [ J PRIVATE ] PUBLIC PROPERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: 3(c_, F e to BUILDING INFORMATION Ui}it Type of ; l No. of Build4ng # Persons No's Estab sl sl t i;selpocees1 Area Sgft Served 3 4 2.. STATE OF FLORIDA DEPARTMENT OF HEALTH - ONSITE SEWAGE DISPOSAL SYSTEM - APPLICATION FOR CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC [w] Existing System Abandonment br 7 Aur CC. zu012-77-1 - 1 - 0 &N APPLICANT'S SIGNATURE: ] RESIDENTIAL [ ] Garbage Grinders /Disposals [ ] Ultra -low Volume Flush Toilets DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1) which may be used) \ (Stock Number: 5744- 001 - 4015 -1) [di Holding Tank [ ij Temporary /Experimental Other(Specify) 770 AA cen 57: dinfi-71 '% [ ] COMMERCIAL ] Spas /Hot Tubs , [ Floor /Equipment Drains ] Other (Specify) L At /,/ S DATE: q ? /J/ PERMIT # DATE PAID FEE PAID $ RECEIPT # 3- TELEPHO 803 z Business Activity For Commercial Only Page 1 of 3 INSTRUCTIONS: 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, city, state and zip code mailing address for applicant or agent. LOT, BLOCK, SUBDIVISION: DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing an approved lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot. PROPERTY ID #: 27 character number for property. (Health Department may require property appraiser ID# or section /township /range /parcel number.) PROPERTY SIZE: Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot legal description or deed must be attached. Net usable area of property in acres (square footage divided by 43,560 square feet) 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. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions may be included in calculating lot area. WATER SUPPLY: Check private or public. PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county. DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location. BUILDING INFORMATION: Check residential or commercial. TYPE ESTABLISHMENT: List type of establishment from Table I1, Chapter IOD-6, FAC. Examples: single family, single wide mobile home, restaurant, doctor's office. NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for occupants. BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully screened patios or decks. Based on outside measurements for each story of structure. # PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are assumed. BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by Table 11, Chapter IOD -6, FAC. FIXTURES: Mark each listed fixture with number installed or "NA" if not applicable. SIGNATURE: Signature of applicant or agent. Date application on day submitted to 1lealth Department with appropriate tees and attachments. ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other features necessary to determine composition and quantity of wastewater.