893 NE 96 st (6)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant /j oe'ck Permit Number 86 — 06
gq3 rl . c . y'6 P/4- 6 196'
PART II - SYSTEM INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL
4
Installer /d�1�'�'•�� Z- Tank Manufactyrer
Pro ertank legend: Yes No Tank material Cd?z�-re' l Tank level: Yes No
P 9 —
Tanks watertight: Yes ' No Tank size: '' gallons gallons gallons
Proper tank outlet device: Yes ! No
Length
feet
feet
teet
Total=
Inspected by
Width
feet
feet
feet
ft
Date/ Approved by:
Drainfield Trench
Proper gravel size: Yes No
( � f3Yr-u I7Ce.) (f
5 O)
P,
Length
feet
feet
feet
AN APPROVED INSTALLATI
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4016-0)
Width
feet
feet
feet
Total = ft
Systems located as permitted: Yes V No
Systems including plumbing stub -outs installed at proper elevation:
Average depth to drainpipe invert from finished grader /•a inches
Average depth of drainfield gravel: /—Ko inches Minimum depth
Backfill or fill material as required: (Quality) Yes " No
Manhole or marker to grade: Yes — No_
Absorption Bed
Length A'- feet x feet = /e .
Gravel is suitable quality: Yes
Length &) feet x 3 •' feet= /6 s; oft2
34 / o
Proper No. drainlines: Yes 7 No
Proper pipe separation: Yes V No
Distribution box level: Yes No
Yes No
Maximum depth•oW°
of gravel: 4 K -i rr inches
No
(Quantity) Yes ✓ No
Other findings*
Date
ALLATION APPROVAL - -• f
OES NOT GUARANTEE PERFORMANCE
OUNTY PUBLIC HEALTH UNIT
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
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