839 NE 97 St (13)D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
CONSTRUCTION PERMIT Jj0R:
0 New System n
[` ] Repair [ p1
APPLICANT:
STATE OF FLORIDA r �.
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
PROPERTY STREET ADDRESS: }
LOT : o s BLOCK: 7 SUBDIVISION:
PROPERTY ID #:
P � �c / U [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. 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
) T -7 I
[�J� ] [GALLONS
A [ ] [GALLONS
N [ ] GALLONS
K [ ] GALLONS / / J
[ ] SQUARE FEET PRIMARY
[ ] SQUARE FEET
TYPE SYSTEM:
CONFIGURATION:
FILL REQUIRED: [
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
V-- ?
xisting System [!] 1ding Tank
[ ] Other(Specify)
Abandonment
L
/}GPD] SEPTIC TANK /AEROBIC UNIT
/ GPD]
GREASE INTERCEPTOR CAPACITY
PER DOSE DOSING TANK CAPACITY
M
DRAINFIELD SYSTEM
SYSTEM
[ ] STANDARD [ ] FILLED
[ BED
[ ] TRENCH
LOCATION OF BENCHMARK: a jFf07rd -*770epoe. _ r �
ELEVATION OF PROPOSED SYSTEM SITE [I 0] [INCHES /FT]
BOTTOM OF DRAINFIELD TO BE [ � ] [aft e-FT]
] INCHES
EXCAVATION REQUIRED:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
Form 4015, Feb 85 (Obsoletes previous editions which may not be used). T -`
her. 5744-002
AGENT:
APPLOCAKIT
MOUND [
CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
CAPACITY MULTI- CHAMBERED /IN SERIES:(
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [
[
[ ]
RECEIPT #
1
[ABOVE /BELOW] BENCHMA /REFERENCE,POINT
[ABOVE BENCHMARK/ EFERENCE POI
[ ] INCHES
PERMIT #
DATE PAID
FEE PAID $ �(
Tem porary /Experimental
TITLE:
TITLE:
EXPIRATION DATE:
Page 1 of 2
Jnit
ff 3
.. FUFi ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number ,,
Plan Approved
By
7
th
Notes: 7.'U 7A41c_
fi
1
Zn
f
i`
Scale: Each block represents 5 feet and 1 inch = 50 feet. �r
Site Plan submitted by:
• g.- 81ZaNATHRe
- STATE OF FLORIDA
- F HEALTH AND REHWILITATIVE SERVICES
PART II - SITE PLA
9 Z ' ,
2 o'er '
r
4
Pv
i' TITLES
Date
Not Approved
County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
' Form 4015, Feb 85 (Obsoletes previous editions which may not be used).: Page 2 Of 3
, her 5744.002.4015 -6) 9
APPLICATION FOR:
[ ] New System [ ]Existing System [
[ X ] Repair [ ]Abandonment
APPLICANT: Corey, Edward
AGENT: SR0921112 , John Tuffy, SR0921112
MAILING ADDRESS:6022 SW 35 Ct Miramar FL 33023
PROPERTY INFORMATION [IF LOT IS NOT
LOT: 8 BLOCK: 78
PROPERTY ID #: 11 - 3206 - 014 - 3310
PROPERTY SIZE: 0.26 ACRES
BUILDING INFORMATION
Unit Type of
No Establishment
[ ] Floor /Equipment Drains
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS
]Holding Tank
]Temporary
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 64E -6, FLORIDA ADMINISTRATIVE CODE.
IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
SUBDIVISION: Miami Shores
PROPERTY STREET ADDRESS: 901 NE 97 St, Miami
[ X ] RESIDENTIAL
ZONING:
[Sqft /43560] PROPERTY WATER SUPPLY:
No. of Building
Bedrooms Area Sqft
[ ] Other (Specify)
APPLICANT'S SIGNATURE:
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4015 -1) (ostds_appl_4015 -1)
CENTRAX #: 13 - - 05797
DATE PAID: 8/16/00
FEE PAID :$ 75.00
RECEIPT : S000816024
OSTDSNBR :00 2809 -
]Innovative
TELEPHONE: 305 944 - 8886
PLATTED: 1/1/32
I / M OR EQUIVALENT: [ Y / N ]
[ ] PRIVATE [ X ] PUBLIC
IS SEWER AVAILABLE AS PER 381.0065, FLORIDA STATUTES? [ Y / N ] DISTANCE TO SEWER:
DIRECTIONS TO PROPERTY:
I - 95 south to 95th St. east to 9th Ave. north to 97th St.west find address
] COMMERCIAL
# Persons Business Activity
Served For Commercial Only
DATE: 8/16/00
FT
Page 1 of 4
FLORIDA DEPARTMENT OF HEAL
LOT: 8 BLOCK: 78
• .STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System [ ]Holding Tank [ ] Innovative Other
[ X ]Repair [ ]Abandonment [ ]Temporary [ ]
APPLICANT: Corey, Edward AGENT: SR0921112, Tuffy John
PROPERTY STREET ADDRESS: 901 NE 97 St Miami FL 33138
SUBDIVISION: Miami Shores
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11 - 3206 - 014 - 3310 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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 PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 750 ]Gallons SEPTIC TANK
A [ 0 ]Gallons
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @
D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED
I CONFIGURATION: [ N ]TRENCH [ N ]BED
N
F LOCATION TO BENCHMARK: 10.60" MSL FF. Elev.
I ELEVATION OF PROPOSED SYSTEM SITE [ 6.0 ] [ FEET
E BOTTOM OF DRAINFIELD TO BE [ 36.0 ] [ FEET
L
D FILL REQUIRED:[ 0.0 ]INCHES EXCAVATION REQUIRED: [ 30.0 ] INCHES
SPECIFICATIONS BY: TITLE:
APPROVED BY: Milian, Jorge TITLE: Engineer I
DATE ISSUED: 8/17/00
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0) [ostds_cons_4016 -1]
CENTRAX #: 13 - - 05797
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 00 - 2809 - -R
MULTI - CHAMBERED /IN SERIES: [Y ]
MULTI - CHAMBERED /IN SERIES: [Y ]
[0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
[ N ]MOUND [ N
[ N ]
] [ BELOW BENCHMARK /REFERENCE POINT
] [ below BENCHMARK /REFERENCE POINT
OTHER REMARKS:
Existing 750 gls. s/t
Install 300 sq. ft. d/f
Install 12" of loamy coarse sand at bottom of d/f
This permit is not for addition(s)
Invert elev. of d/f to be no less than 8.10" MSL
Bottom of d/f elev. to be no less than 7.60" MSL
Perimeter of excavation shall be 2ft. wider & 2ft. longer than proposed absorption bed or
drain trench
Dade
EXPIRATION DATE: 11/15/00
CHD
Page 1 of 2
CONSTRUCTION PERMIT FOR:
[ >1 J New System [ 0 Existing System [ Holding Tank [ N] Temporary /Experimental
( ,J) Repair ( J) Abandonment [ ] Other(Specify)
APPLICANT:
m Cti Lai
PROPERTY STREET ADDREtS:
LOT: BLOCK:
J? 1
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
T
A
N
K
D
R
A
I
N
F
1
E
L
D
0
T
H
E
R
LOCATION OF BENCHMARK: ' 2./ ® / /CO L
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
13 I brei
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6,
11- o' -OJ( Z.CQO0
DH 4016, 10/96 (Replaces HRS -H Form 4016 (page 11 which may be used)
(Stock Number: 5744- 001- 4016 -0)
. s z
G.6
7. ! (f`. L
,f9
Applicant
AGENT:
SUBDIVISION: (�
j J /017, 7 vYPS
[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.
GA GALS GPD] TC"`TANKAEROBIC UNIT CAPACITY MULTI- CHAMBEREI /In ]
GALLONS" GPD] JJ CAPACITY MULTI- CHAMBERED /IN SERIES:(
GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
GALLONS PER DOSE DOSING TANK CAPACITY DOSE KATE [ J PER 24 HRS NO. OF PUMPS: [ ]
[ ,/" ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
( �� ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ J [ ] FILLED
CONFIGURATION: [ ] TRENCH [ ,]/ BED
7: d1 0 4 " A'Z r 1 O r ✓t y `� OXi,/3 sl ,:e,
TITLE:
J EIr d°
FAC
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
] MOUND [ ]
]
FT] [ABOVE SELL BENCHMARK FERRNCE -POIN,
( NeH S3 FT ] [ABOVE/ � BENCHMARK FERENCEr-f CIi /I
FILL REQUIRED: [r1 ] INCHES EXCAVATION REQUIRED: [ 7i 1 INCHES
it. L f 1 1 3 rJ 6 i t 11 c f k'
C 1 f[;t1
(i 0 0 e
2 %
TITLE: CHD
EXPIRATION DATE:
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 10D -6, FAC.
DRAINFIELD: Minimum specifications from Chapter IOD -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.
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.
��r
CONSTRUCTION PERMIT FOR:
[ -;] New System [ ,' ] Existing System (,;'] Holding Tank ("A Temporary /Experimental
[ ;] Repair [f -] Abandonment [ Other(Specify)
APPLICANT: AGENT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
BLOCK:
SYSTEM DESIGN AND SPECIFICATIONS
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 10D -6, FAC
y „D
• r • •
SUBDIVISION:
[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.
T [! ) ]'[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 [ ' ! ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ -- ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ °] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH LA BED [ ]
N
F LOCATION OF BENCHMARK: - • t= . -'' ✓ •
I ELEVATION OF PROPOSED SYSTEM SITE ['; )] [INCHES /FT] [ABOVE /BELOW' BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ `. ] (:INCHES /FT] [ABOVE /BELOW) BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: ( ] INCHES EXCAVATION REQUIRED: [ ] INCHES
O _ o 'k .,. .._.: v eve ) ^ 1 1
T
DH 4016, 10/96 (Replaces HRS -H Form 4016 (page 11 which may be used)
(Stock Number: 5744- 001 - 4016 -0) 9
TITLE: r
Insta11er /Co.flractter
TITLE: CHD
EXPIRATION DATE:
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 1OD -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -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.
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.
LOT: / 7 1 gL (kid i f / BOCK: 73
SUBDIVISION: ,(n /Qi ! �'lIOX2S c�� C�r� / /7vl /V e
PROPERTY ID #: /1_ 32 G 6- O 1 - 2 6 Q
TO BE COMPLETED BY ENGINEER,(HEALTH UNIT EMPLOYEE, OTHER QUALIFXED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER ARID SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [YES [ ]
'TOTAL ESTIMATED SEWAGE FLOW: 2_00 GALLONS
AUTRORIZED SEWAGE FLOW: ZOO GALLONS
UNOBSTRUCTED AREA AVAILABLE: 0 0 2 0 SQFT
BENCHMARK /i�2EFERENCE POINT,LOCATION: / 2 . /0 /v), J . L. 1- f /O r' 6:70i,
ELEVATION OF PROPOSED SYSTEM SITE IS 3 S. s a [KMCH FT] [ =OVE/ ELOW `:, ENCEMAR1IREFERERICE POIb
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO T FOLLOWING LAP ATU]Ss
SURFACE WATER: 19 N.v., FT DITCHES /SWALES: A) 0Y FT _ t NORMALLY WET? [ J YES Q �NO
WELLS: PUBLIC: /J GhJ FT LIMITED USE: ,U//-1 FT PRIVATE: ,J4YU FT NON - POTABLE: l`J J FT
BUILDING FOUNDATIONS: 5.00 FT PROPERTY LINES: G.0 FT POTABLE WATER LINES: / 0•.) ✓ FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ 4 NO 10 YEAR FLOODING? [ J YES [,/'NO
10 YEAR FLOOD ELEVATION FOR SITE: 5.0C) FT MSL /NGVD SITE ELEVATION: .ly FT MSL /NGVD
SOIL PROFILE INFORMATION`'SITE 1 0J , � . - 3, 00' /- 3, C . SOIL PROFILE INFORMATION SITE 2
Munsell #/C for
l a'/ R 5/1
v y
107k s/a
H �•
01
Texture
S cepi cl
f
Depth
to
to
to 10
1 O to I -
to
to
to
to
G. ! Li 1 6111 -7- to 7 Z
USDA SOIL SERIES: 4 f) - / S
^ I / /Z,3 /ZS, = I (I 0 ) tp
'
OBSERVED WATER TABLE: l 1 INCHES [ABOVE /C ELOW U EXISTING GRADE. TYPE: [PERCHED / ' PPARENTJ,
ESTIMATED WET SEASON WATER TABLE ELEVATION: 7 y INCHES [ ABOVE / (pELOW)] EXIS ING GRADE:
HIGH WATER TABLE VEGETATION: [ ] YES ['j' NO MOTTLING: [ ] YES [✓f NO DEPTH: ;U 9 INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: a'7 0 DEPTH OF EXCAVATION: 7Z INCHES
DRAINFIELD CONFIGURATION: [ TRENCH [ "J [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA: /W / e -« c 4 iO
o �. ' ,AiCYfb o. f
SITE EVALUATED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
4- a lit el 4 CQ Cy 0 AGENT: 4/i
HRS -H Form 4015, :Aar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1)
[Section /Township /Range /Parcel No. or Tax ID Number]
8'3 E, c 7 J � : 4. r -/. 33 1 3
NO NET USABLE AREA AVAXLABLEs 0 .'32 ACRES
PER DAY [RESIDENCES- T.,!':.LE 11 / OT ER-TABLE 2]
PER D [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA REQUIRED: S 7 ) SQFT
PERMIT # I 1` « 3 Oz
DATE:
Munsell # /Color Texture
loyR sal Sid
cr
/0(
h
Depth
to
to
to / !)
4. I C I C1 Ira S c I (1 t0
N — to
V to
N o t0
LII h c7rii cam -4,:z to 7 41
USDA SOIL SRIES: M a p - /.
Page 3 of 3
i1STi.UCT'ONS:
PERT. :1T 0:
AGENT:
LOT, F LOC.7, Lot, bk s 7 c, ar:.; cubdiv eio
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
BEVCHMARK
[f] SHOT:
H.R.
nuo, c . rr >. oy c
a l T\! :: l;: ?7 ;ha, , a.:, el■m'ces c: Te a ip. (property a)i,: ^sr ID ,'+ or aection/township /range /parcel number)
Caeca: '1 :.;opecty sire z r:?e cartfonns to submitted site plant. necord net usable area available -lot area exclttcive of
all :<;vec areas and preperad .c :d.eels within hts -an way or ease;.ants and exclusive of dreams, lakes,
sorrutly wet drainage ditches, marshes, or other such bodies of water.
Record the estimated s.:wage flow for the establishment front Table 1 (residences) or Table 2 (non - residential), Chapter
10D-6, :FAC. Record the authorized sewage flow for the lot bac d on net usable area and water supply (1500 gallons
per day per acre for private .rater capplies and 2500 gpd per acre for public water supplies). If authorized =wage flow
does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2
time as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum
setbacks in Chapter 1OD -6, FAC. The unobstructed area must be contiguous to the drainfield.
IBENCHMA_R? INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of' the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA"
for non applicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location
of any public drinking well within 200 feet of the applicant'a lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For Tots subject to flooding record 10 year flood elevation for site and
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must
be clearly documented. Provide USDA soil series if available, record "UNIC" if the series cannot be determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and
historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINF!ELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted.
ELEVATION WORKSI: LHV AT1ON OF BENCF_MARI's 1 REFERENCE POINT IS:
SrrE
H.1.
[ -] SHOT
SITE 2
H.I.
[ -] SHOT
SITE 3
H.I.
[ -] SHOT
APPLICATION FOR:
] New System [ ] Existing. System [ ] Holding Tank [ ] Temporary /Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT:
AGENT: /j ;I/
MAILING ADDRESS:
TO 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:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION p<] RESIDENTIAL
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Sqft Served For Commercial Only
1
2
3
4
1- /y as are (I)
[ ] Garbage Grinders /Disposals
pr 7—A,Ultra -low Volume Flush Toilets
APPLICANT'S SIGNATURE:
#: // - 3 2000-014-2.610
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 1) which may be used)
(Stock Number: 5744- 001 - 4015 -1)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
SUBDIVISION:
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PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
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SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
[Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
[ ] Spas /Hot Tubs [ ] Floor /Equipment Drains
[ ] Other (Specify)
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DATE:
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:
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.
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 IDti or section /township /range /parcel number)
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 II, Chapter 10D-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 II, Chapter 1OD -6, FAC.
FD{TURES: Mark each listed fixture with number installed or 'NA" if not applicable.
SIGNATURE: Signature of applicant or agent. Date application on day submitted to Health Department with appropriate fees 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.