934 NE 98 St (6)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant G.r' /64 -! a A. /9 Lic ik ) Pv Number ij7 - 8•.4.
PART II - SYS EM INSTAL TION INSPECTION AND FINAL INSTALLATION APPROVAL
Installer (SR -E<! T -"Z r i--/ -'-
Proper tank legend: Yes ' No Tank material H AI / 4-s; Tank level: Yes ■ No
Tanks watertight: Yes ■•` No Tank size: — gallons -- gallons /
gallons
Proper tank outlet device: Ye ...--` No Manhole or marker to grade: Yes — No
Dralnfield Trench
Tank Manufacturer C 13 /-'
Absorption Bed
Length Width Length Width Length 3 (- feet x_ feet = bile2,,ft
feet feet feet feet Length -- feet x - ' — ft 2
feet feet feet feet Proper No. drainlines: Yes - No 0)
feet feet feet feet Proper pipe separation: Yes ✓ No
Total =
Date
Approved by
ft Total = ft Distribution box level: Yes No Wilk--
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: / `finches Maximum depth If Inches
Average depth of drainfield gravel inches Minimum depth of gravel: _l3 inches
Proper gravel size: Yes 1 -"` No Gravel is suitable quality: Yes No
Backfill or fill material as required: (Quality) Yes No
Other findings:) S1f11-e , U
• 7� ri
Inspected by: t7n- 1- Cr /7 /4jJc�,4
AN APPROVED INS
Note: Completed copies of this form will
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744002 - 4016 -4)
(Quantity) Yes —' No
f 1) Date 0
PART II - FIN44INSTALLATION APPROVAL
TION D • ES NOT GUARANTEE PERFORMANCE
COUNlae UNIT
e provided to the applicant, installer and the building department.
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