273 NE 98 St (14)Date
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant . J!_ Permit Number �� /3 ?
PART II - SYSTEM I N S TA L TIO INSPECTION AND FINAL INSTAL TION APPROVAL - - ---
� QQ-'' � f6 C. l - Tank Manufacturer . �,
Installer �
Proper tank legend: Yes____. No Tank material 2 -6.. Tank level: Yes // No
Tankswatertight: Yes No jizfr
Proper tank outlet device: Ye
Drainfieid Trench
Length 1Nidth
feet _ feet
feet __ feet
feet __ feet
Total = ft
Inspected by: a-9, L-
Systems located as permitted: Yes 1ST No
Systems including plumbing stub -outs installed at proper elevation: Yes No
Average depth to drainpipe invert from finished grade: Jf inches Maximum depth: Inches
Average depth of drainfield gravel: inches Minimum depth of gravel ( inches
Proper gravel size: Yes No Gravel is suitable quality: Yes LI No
Backfill or fill material as required: (Quality) Yes _ No (Quantity) Yes r■/ No
GI
Other findings 't
PART III
Length Width
feet feet
Approved by: p .;'
T
AN APPROVED INSTAL •`/TIO I ►�
Tanksize gallons ---- gallons
INA
Manhole or marker to grade: Yes —C' No
Absorption Bed
Length feet x JL' feet = &t ® ft
Length � feet x �" feet = ft
ALLATION APPROVAL
feet feet Proper No. drainlines: Yes V No ff
feet feet Proper pipe separation: Yes No
Total = ft Distribution box level: Yes No
Datej lig /0
COUt�JTY P BLI�LTH UNIT
OES NOT GUARANTEE PERFORMANCE
gallons
Note: Completed copies of this form will b ; provided to the applicant, installer and the building department.
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744-002-4016-4) Page 2 of 2