251 NE 98 St (3)CONSTRUCTION PERMIT FOR:
r, New System [ ) Existing System
[ /) Repair [ j Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID 0:
__________________________== =:=sass ===z====== =m== ==
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.
SYSTEM DESIGN AND SPECIFICATIONS
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BLOCK: SUBDIVISION:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS &
] / GPDJ.SEPTIC TANK /AEROBIC UNIT. CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] (GALLONS ~ / GPD] CAPACITY MULTI - CHAMBERED /IN SERIES:( ]
] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS PER DOSE DOSING TANK CAPACITY DOSE•RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
). SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET
TYPE SYSTEM: [ ] STANDARD
CONFIGURATION: [ ] TRENCH
M
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE [
FILL REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
•
OH 4016, 10196 (Replaces HRS -H Form 4016 [page 1) which may be used)
(Stock Number: 5744 - 001. 4016 -0)
1/
Chapter 10D -6, FAC
)Holding Tank [ J Temporary /Experimental
Other(Specify)
[SECTION /TOWNSHIP /RANGE /PARCEL !UMBER)
[OR TAX ID NUMBER)
SYSTEM
[ ] FILLED
[ ] BED
J INCHES /M] [ABOVEC{..BELOW ENCHMARI( /REFER$ACR-P OW
K( INdffES/FT) (ABOVE7BELOn BENCHMARKfaFERLNCE P9
INCHES EXCAVATION REQUIRED: [._2' ') INCHES
� O
AGENT:
TITLE:
TITLE:
[ ]
[ ]
BUILDINU DEPARTMENT
MOUND
r
PERMIT 0 i' / /
DATE PAID --
FEE PAID =
RECEIPT 0 1% 'i- 2 71
C.
se¢a=
EXPIRATION DATE:
Page 1 of 2
,-t44 (406) 13 '33SSVHV11VI SOP
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 IOD -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.