795 NE 97 St (2)APPLICATION FOR:
] New System [... ] Existing System [d. ] Holding Tank Ls ] Temporary /Experimental
J Repair [... ] Abandonment [ ..`' ] Other(Specify)
APPLICANT: :. _' ::; TELEPHONE:
AGENT: e::.... :.: '.......0
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:
BUILDING INFORMATION
Unit Type of
No Establishment
STATE OF FLORIDA PERMIT # _
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
APPLICATION FOR CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
ACRES [Sqft /43560]
SUBDIVISION:
1 S 2
2
3
4
DATE OF . _
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
PROPERTY WATER SUPPLY: [ ] PRIVATE [; "''J PUBLIC
[ - RESIDENTIAL [ ] COMMERCIAL
No. of Building # Persons Business Activity
Bedrooms Area Sqft Served For Commercial Only
Floor /Equipment Drains
[.:] Garbage Grinders /Disposals [ .:] Spas /Hot Tubs
[ . ] Ultra -low Volume Flush ' J oilets [ :. ] Other (Specify)
APPLICANT'S SIGNATURE G �/� f DATE:
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock !lumber: 5744 - 001- 4015 -1)
Page 1 of 3
CONSTRUCTION PERMIT FOR:
C- New System [ / \'] Existing System
[may Repair [ Abandonment
<
APPLICANT: R, G � =
�' 7 :, \, 1 '' �
PROPERTY ADDRESS:
r is
LOT: /9 % 6J- 6 BLOCK: G SUBDIVISION:
PROPERTY ID # : &' � � � / ( ° - -- ,?' N G--tip)
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESI AND SPECIF
T [ 7] GALLONS / GPD 5
A [ ] GALLONS / GPD
N [ ] GALLONS GREASE
K [ ] GALLONS DOSING
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
APPROVED BY:
SPECIFICATIONS BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND. - DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CATIONS
iPTIC T
SQUARE FEET
SQUARE FEET
TYPE SYSTEM: [7
CONFIGURATION:]
r =:
LOCATION OF BENCHMARK: 7G�0 ti '7" r rC l
ELEVATION OF PROPOSED SYSTEM SITE [ Q. j]
BOTTOM OF DRAINFIELD TO BE (�'F
DH 4016, 12/99 (Page 1) (Previ us._ 10
[ §4] Holding Tank [G y,' Innovative
4
[ /� Temporary E,1%
�R>
PERMIT NO./ % /r c .
DATE PAID:
FEE PAID:
RECEIPT #:
f o�
[SECTION, TOWNSHIP, RANGE,
[OR TAX ID NUMBER]
/r
PARCEL NUMBER]
/AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
TANK CAPACITY [ ]GALLONS @ [ ] DOSES PER 24 HRS # PUMPS ( ]
PRIMARY DRAINFIELD SYSTEM
/
SYSTEM 2 ��
STANARD FILLED `,MOUND (Al TRENCH [ 4 BED [
[INCHES /] [ABOVE/BO] BENCHMARK /REFERENCE POINT
[ CI /FT' [ABOVE/i40)] BENCHMARK /REFERENCE POINT
FILL REQUIRED: ( ;� ] INCHES EXCAVATION REQUIRED: [
INCHES
(
TITLE: AA 1 /9 � � .
M
BEE '; Used)
.
<a�
TITLE:
1: ‘h :te;
n ". 3 lnsfai( rlc i e�:.
pt. 4: 13uilein j Do crI/ 1// ;
P
EXPIRATION DATE:
Page 1 of 3
INSTRUCTIONS:
PERMIT NUMBER:
CONSTRUCTIION
PERMIT IFO 0'.' :
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
LIT, :.LOCK, SUB iNISI siN or
PROPERTY IlIID #:
SYSTEM ESIGN AND
SPECIFICATIONS:
TANK:
®1RAINFIIELID:
OTHER +::
SPECIFICATIONS E:; Y:
APP OYEZ) BY:
DATE IISSUEIID:
Permit trashing number assigned by CPHU.
Check type of permit, iff "Other" specify type in blank.
Property owner's TWO name.
Telephone number for applicant or agent
Property owner's legally authorized representative.
P.O. I1ten or street mailing address or applicant or agent.
7
27 character id number for property. (CHID may require property appraiser RD # oP section/township/range/parcel number)
Minimum specifications from Chapter 64E.6, IFAC.
Minimum specifications from Chapter 64E-6, PAC.
Other specifications, saach as operating permit requirements, low - volume Olush toilets, variance provisos.
Name of individual providing specifications. If designed by a registered engineer Most be sealed.
County (Heald: (Department (CH D) personnel reviewing and approving permit.
(Date permit is issued by CI-IID
EXPIRATION DATE: One year from slate issued lithe system has not been installed. (Permits for system repairs become void ;3 days Groat: the date
issued.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT -; /
Permit Application Number
Scale: Each block represents 5 feet and 1 inch = 50 feet.
PART II SITE PLAN-
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Site Plan submitted by
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Signatu
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Plan Approved ii _
.
, Not Approved /D ate
_
By 15 -- ,-1- '-■ . ;(; , ' Q<>e;- County Health Department
z,
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-6)
Page 2 of 3