790 NE 97 St (12)CONSTRUCTION PERMIT FOR:
[ T New System [ %`] Existing System [ %] Holding Tank
[ ] Repair [ J'Abandonment [ iJ Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
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SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
[
o AGENT:
•
FEE PAID $
RECEIPT #
. Temporary /Experimental
LOT: BLOCK: SUBDIVISION: ( -24
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
s'� 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 WHICE SERVED AS
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.
T 1 ° ='] [GALLONS / GPD]-SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES: ]
A ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:' ]
N 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K ] GALLONS PER DOSE. DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [ /1 SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ,] BED [ 1
N
F LOCATION OF BENCHMARK: G „l 4,,,, / , / ; 7 /„-' t i
I ELEVATION OF PROPOSED SYSTEM SITE V CINCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ '// `]- [INCHES /FT] [ABOV /BELOW] BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ INCHES
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
TITLE: - CPHU
EXPIRATION DATE:.
Page 1 of 2
N ales:
Site Pian Submitted by:_
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
13'3 - Fn -� 4015, Fr'e 85 (CS5o' ^5 ^s crevicus editions which may not f:e used)
57"i:4-05?-40'5-G)
PART I - SITE PLAN
SIGNATURE
:- Iar. Approved Not Approved
, ' �o ,
�_ L'Yl� . �Oc ^ - ��.. y J , �
Date
County Public Jn t
%Ce 2al: 3