869 NE 98 St (8)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SE GE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant "/ 4.4 e_d rmit Number - 5
IC A), 6 . sr- -# 7
PART II - SYSTEM INSTALLATION INSPECTION AND FINAL INSTALLA O PPROVAL
Installer / � ' j i f / - / � - t VimNe & -1
Proper tank legend: Yes
Tanks watertight: Yes
Proper tank outlet device:
Proper gravel size: Yes ` /No
Inspected by: V f cf
(Stock Number. 5744.002.4016.0)
Q A-,
Drainfield Trench
Tank Manufacturer
Tank material C Tank level: Yes
Tank size: gallons —gallons
Gravel is suitable quality: Yes x/11 No
Backfill or fill material as required: (Quality) Yes V No (Quantity) Yes C /No
Other findings
012-64/4 (CY( u '�-
/Oa-
gallons
Manhole or marker to grade: Yes
Absorption Bed
Length Width LOAM Width Length Pt ° feet x r feet = J ‘ 0 ft
feet feet feet feet Length / 1 feet x 5 feet = 5 ft
a'iS
feet feet feet feet Proper No. drainlines: Yes JT No
feet feet/ 1 feet feet Proper pipe separation: Yes _ No
Total = ft Total = ft Distribution box level: Yes No 44---
Systems located as permitted: Yes I No
Systems including plumbing stub -outs installed at proper elevation: Yes__ No 7
Average depth to drainpipe invert from finished grade: / C inches Maximum depth '�� Inches
Average depth of drainfield gravel: inches Minimum depth of gravel / 'finches
Date o f 1i f g,C
No
PART II F A STALI -ATION APPROVAL ••
Date A roved by: (t � d e--- y COUNTY LIC HEALTH UNIT
AN APPROVED INST • N DO =S NOT GUARANTEE PERFORMANCE
Note: Completed copies of this form \ be provided to the applicant, installer and the building department.
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may no be used)
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