828 NE 97 St (3)O
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CONSTRUCTION PERMIT FOR:
[E,] New System [ C�]
Repair [b�]
APPLICANT:
PROPERTY ADDRESS:
LOT:
PROPERTY ID #:6
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D FILL REQUIRED:
APPROVED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT ANDD*SPOSAL SYSTEM
CONSTRUCTION PERMIT--,
DATE ISSUED: i 0 ° J'
Existing System UV]
Abandonment [�°]
BLOCK: SUBDIVISION:
o C C
Holding Tank
Temporary
PERMIT NO . !/l , i c ! <' /j
DATE PAID: F' OF; . -
FEE PAID: ° ' c , ,
RECEIPT # (--,/ u'd(
LA) Innovative
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[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
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 SAFT:ISFACTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A
BASIS FOR ISSUANCE OF TEIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION.
SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OF TICS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ ] GALLONS / GPD 4PTIC TANK AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
A [ ] GALLONS / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ] GALLONS @ [ ] DOSES PER 24 MRS # PUMPS [ ]
SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: (J STANARD [ 4\j FILLED [Al MOUND [ ]
CONFIGURATION: ] TRENCH [y] BED ma•']
LOCATION OF BENCHMARK:
'-)%
f) (/ 1 *4 a — , o) ,n Or2 . F
ELEVATION OF PROPOSED SYSTEM SITE [von] [INCHES/1 ]
BOTTOM OF DRAINFIELD TO BE (g s l, [ rCHE /FT]
'i',,- ] INCHES EXCAVATION REQUIRED: [ A e ] INCHES
DH 4016, 12/99 (Page 1) '(Prejlpua Edxtzone May Be Mead)
TITLE: r
[ABOVE/ LL ] BENCHMARK /REFERENCE POINT
[ABOVE / O BENCHMARK /REFERENCE POINT
Jt't. @7!E'.PI��
4JN •.i Vll-•• ... .c.: �.. i.
SPECIFICATIONS BY: / TITLE:
g •;E•h Department
pt. 2: Applicant
pt. 3: I nstaller /Contractor
pt. 4: Building Department
CHD
EXPIRATION DATE: G / 0•••/', r';'O
Page 1 of 3
INSTRUCTIONS:
PERMIT NUMBER:
CONSTRUCTION
PERMIT FOR:
APPLICANT:
Check type of permit, if "Other" specify type in blank.
Property owner's full name.
TELEPII ^1 NE: Te:ephone 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 tD #: 27 character it number for property. (CND may require property appraiser ID # or section/township /range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
DRAINIFIELD: Minimum specifications from Chapter 64E-6, PAC.
OTIIE','': Other specifications, such as operating permit requirements, low-volume flush toilets, variance provisos.
SP}ECBFICATI4 9NS or If: Name of individual providing specifications. Iff designed by a registered engineer must be sealed.
County Idealth Department (CIID) personnel reviewing and approving permit.
Date permit is issued by CHD
APPROVED BY:
DATE ISSUED:
EXPIRATION DATE:
Permit tracldng number assigned by CPHU.
Minimum specifications from Chapter 64E-6, IFAC.
One year frcaan date issued if the systems has not been installed Permits for system repairs became void 93 days from tLe date
issued.
LOT:
PROPERTY ID #:
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 SI".TE PLAN:
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
BENCHMARK /REFERENCE POINT LOCATION: _
ELEVATION OF PROPOSED SYSTEM SITE IS : !� ` r INCHES
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE
SURFACE WATER: FT DITCHES /SWALES:
WELLS: PUBLIC: FT LIMITED USE: FT
SITE SUBJECT TO FREQUENT FLOODING:
10 YEAR FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE 1
Munsell # /Co1or
Texture Depth
USDA SOIL SERIES:
to
to
V — Ito
tso
to
tor
to \
to
REMARKS /ADDITIONAL CRITERIAs --
SITE EVALUATED BY:
/. .
AGENT:
ter, •
•
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1)
PERMIT #
[Section /Township /Range /Parcel No. or Tax ID ?umber]
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.
,1 YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
GALLONS PER DAY [RESIDENCES —TABLE 1 / OTHER — TABLE 2]
t 'ji GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
FT] [ABOVE /BELOW/,BENCHMARK /REFERENCE POINT
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
, FT NORMALLY WET? [ ] YES [ ] NO
PRIVATE: FT NON— POTABLE: FT
FT PROPERTY LINES: FT POTABLE WATER LINES: FT
[ ] YES kl NO 10 YEAR FLOODING? [ ] YES [ ] NO
J ✓I 4 FT MSL /NGVD SITE ELEVATION: � FT M,SL /NGVD
»- SOIL PROFILE INFORMATION SITE 2
Munsell # /Color
( , =�
Texture .
USDA SOIL SERIES: !
OBSERVED WATER TABLE: / -INCHES [ABOVE / BELOW]. EXISTING GRADE. --- TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: -- �! . / INCHES [,ABOVE' 1 BELOW j EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: ' DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: u ] TRENCH [_ - "' BED [ ] OTHER (SPECIFY)
/.,
i
//
DATE:
Depth
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Page 3 of 3
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