352 NE 98 St (5)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant 6�'! A q . 2 PeAnit Number g 5'
.3-6-02 d . 5 �" ‘74- `'
PART II - SYSTEM INSTALLATION INSPECTIONAND FINAL I APPROVAL
(& 61-t Manufactu!'er S )�'
Proper tank legend: Yeses No Tank material Tank level: Yes
Installer / 1112 " ,- 7 - 4 e rt , , �7dsv,k
Inspected by
Tankswatertight: Yes_, No
Proper tank outlet device: Ye
Dralnfield Trench
Length Width Length Width
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which ay be used)
(Stock Number: 5744-002- 4016 -4)
Tank size: — gallons / 0 gallons
Manhole or marker to grade: Yes /1 ir No
Absorption Bed
Length_g_Q feetx /r7 feet=
Total= ft Distribution box level: Yes No
Systems located as permitted: Yes ✓ No
Systems including plumbing stub -outs installed at proper elevation: Yes No
Average depth to drainpipe invert from finished grade: inches Maximum depth Inches
gallons
feet feet feet feet Length feet x feet= °-> ft
feet feet 1 feet feet Proper No. drainlines: Yes t7No
feet fee feet feet Proper pipe separation: Yes i/ No
Total = ft
Average depth of drainfield gray / ', inches Minimum depth of gravel (01.- inches
Proper gravel size: Yes No Gravel is suitable quality: Yes ✓ No
Backfill or fill material as required: (Quality) Yes L) No (Quantity) Yes ✓ No
Other findings a.�•
Date .3/
PA : T III - FI N ft INSTALLATION APPROVAL
Date Approved by ■ ► �"/�
SCt
COUNTY PUBLIC HEALTH UNIT
AN APPROVED INS DOES NOT GUARANTEE PERFORMANCE
Note: Completed copies of this forme. •e provide • to the applicant, installer and the building department.
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