157 NW 98 St (9)APPLICATION FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[1G] Repair [ ] Abandonment ( ] Other(Specify)
APPLICANT:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
l�l DO (z__
AGENT: c ^ L 4 E7
.1754 o � C5r 'a 4
MAILING ADDRESS: ,."
C
BLOCK:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
APPLICANT'S SIGNATURE:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
SUBDIVISION:
SEPTIC TANK CONTRACTOR:
,)
PERMIT 1
DATE PAID
FEE PAID $
RECEIPT 1
TELEPHONE: i V
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [pp/ PRIVATE ] PUBLIC
% S7 9J 57_ `2,- i;(
[j RESIDENTIAL [ ] COMMERCIAL
No. of Building 1 Persons
Bedrooms Area Sgft Served
7nt )
MRS -H Form 4015, Mar 92 (Obsoletl's previous editions which may not be used)
(Stock Number: 5744- 001-4015 -1)
DATE:
Business Activity
For Commercial Only
[ ] Garbage Grinders /Disposa }s [ ] Spas /Hot Tubs [ ] Floor /Equipment Drains
[ ] Ultra -low Volume Flush Toilets [ ] Other (Specify)
, / I 1{
Ik
Page 1 of
APPLICANT: [ OY1 002
LOT:
PROPERTY ID #:
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUS
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [
TOTAL ESTIMATED SEWAGE FLOW: q5
AUTHORIZED SEWAGE FLOW: VSO
UNOBSTRUCTED AREA AVAILABLE: 300
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH
SURFACE WATER: FT
WELLS: PUBLIC: FT
• , v BUILDING FOUNDATIONS:
SITE£UBJECT TO FREQUENT FLOODING: [ ] YES pt] NO
10 REAR FLOOD ELEVATION FOR SITE: S".7 FT MSL /NGVD
t. 1
•. --SOIL PROFILE INFORMATION SITE 1
Munsell # /Color
to
USDA SOIL SERIES: d■-c, �� (707 °rr
Texture Depth
`t U eSv A- U to t T
S7F!ll�d� /Z to
to
to
to
to
to
to
OBSERVED WATER TABLE: () INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT
ESTIMATED WET SEASON WATER TABLE ELEVATION: t -/1 -D INCHES [ ABOVE / BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ ] YES NO MOTTLING: [ ] YES 9d NO DEPTH: INCHE
SOIL.TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ )4' BED [ ] OTHER (SPECIFY) •
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY: _i6
HRS -H Form 4015, Mar 92 (Obsole which may not be used)
,.-' 5744 - 003-4015 -1) t
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
IL; `! C :J
CAN BE MAINTAINED FROM THE
DITCHES /SWALES:
LIMITED USE: .- FT
FT PROPERTY LINES:
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture
c )'-- 1
USDA SOIL SERIES:
PERMIT #
AGENT: ' r R
[Section /Township /Range /Parcel No. or Tax ID Number
YES [ NO NET USABLE AREA AVAILABLE• ACRE
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: - : 1 v SQF
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
FT NORMALLY WET? [ ] YES [J`] N
PRIVATE: FT NON - POTABLE* F
5 FT POTABLE WATER LINES: /cJ F
10 YEAR FLOODING? [ ] YES `e] N
SITE ELEVATION:_ 7'- FT MSL /NGV
„Z DEPTH OF EXCAVATION:
Depth
to
to
to
to
to
to
to
to
to
INCHE
DATE:
Page 3 of
Oro
Site Plan Submitted by
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PEIR
Permit Application Number ,/ /A
i9/ 7
PART II - SITE PLAN
i
r,
Notes
SIGNATURE
Plan Approved
By " ' = County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
ARS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
Stock Number: 5744-002-4015-6)
Not Approved
TITLE
Date
Page 2 of 3
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary/Experimental
[N] Repair [ ] Abandonment [ ] Other(Specify)
- L. j vi s-
PROPERTY STREET ADDRESS:
APPLICANT:
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK: SUBDIVISION:
SYSTEM DESIGN AND SPECIFICATIONS
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
/ 7 IJ. �v.
AGENT:
JJ (J (> d -
PERMIT # / ik - J 1 ;I 7
DATE PAID 3 - 22-14
FEE PAID $ 4 10 0
RECEIPT # 4 is `)
114'f r
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
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. HRS 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.
T [ ; x% /4] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI CHAMBERD /IN SERIES:[ ]
A [ _ ] [GALLONS / GPD] CAPACITY MULTI CHAMBERED /IN SERIES:[ ]
N [ — ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ - ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [ ) 1 SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ -- ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ k. 1,- STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ,BED [ ]
N
F LOCATION OF BENCHMARK: L.) II)
I ELEVATION OF PROPOSED SYSTEM SITE 6.) [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERVfCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ., ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [t_ %Id-] INCHES EXCAVATION REQUIRED: [ ] INCHES
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (0bsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
INSTALLER/CONTRACTOR
i � l I l4 0 d 1.,.i 1 j J..1 . r P,:
EXPIRATION DATE:,
CPHU
Page 1 of 2