700 NE 96 St (4)STATE OF FLORIDA
DEPARTMENT OF HEALTH AN +' REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
, Applicant / 3 c' i L e ,¢. Permit Number 8 b— /5/6
PART 01 SYSTEM INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL
v
de'( "e sS 7 a� m �: /, t 9g S T
Installer / Al;
Propertank legend: Yes
Tankswatertight: Yes
Proper tank outlet device:
Length width
feet feet
feet feet
feet feet
Total = / ft
No Jl
,$No
YesPo
Drainfield Trench
Systems located as permitted: Ye� No
Average depth to drainpipe invert from finished grade: p= inches
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4016-0)
Tank Manufacturer
Tank material C ,0N��� Tank level:
Tank size:
d. Y
'F gallons
Inspected by 4 / -- / F z/ 1i �i� C6 ��
-F
Yes
Manhole or marker to grade: Yes
Length with • Length / 6 feet x
feet feet Length feet x
feet feet
feet feet
Total = ft
gQ f a3-2
PART I FINAL INSTALLATION APPROVAL
Date 6 1 k‘Approved by
Absorption Bed
C g feet = r O ft2
30
71 S feet =o'Z3o ft
Proper No. drainlines: Yes No
Proper pipe separation: Yes k No
Distribution box level: Yes
Systems including plumbing stub -outs installed at proper elevation: Yes No /
Maximum depth* t= Inches
Average depth of drainfield gravel: inches Minimum depth of gravel*_ inches
Proper gravel size: Yes f/ No
Gravel is suitable quality: Yes V No
Other findings:
AN APPROVED INSTALLATION DOES NOT GUARANTEE PERFORMANCE
gallons gallons
No
Date e / /
COUNTY PUBLIC HEALTH UNIT
No 'v /4-
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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