1135 NE 100 St (13)Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 10/14/2004
Applicant: THOMAS
Owner: WENSJOE
JOB ADDRESS: 10015
Contractor A SUPER SEPTIC TANK, INC.
Local Phone: 305 - 940 - 2828
Parcel # PARC2003 -17
BISCAYNE
Legal Description:
Signed: (INSPECTOR)
Plumbing Permit
Permit Number: PL2004 -290
WENSJOE
THOMAS
BLVD.
Contractor's Address: 7701 W. 18 LANE
Page 1 of 1
Fees:
FEE2004 -10075
FEE2004 -10077
FEE2004 -10078
FEE2004 -10079
FEE2004 -10080
Description
Building Fee
CCF
Notary Fee
Technology Fee
Training and Education Fee
Total Fees:
Amount
$350.00
$2.40
$5.00
$8.75
$0.80
$366.95
Total Fees: $366.95
Total Receipts: $0.00
Permit Status: APPROVED Permit Expiration: 4/5/2005 Construction Value: $4,000.00
Work: DRAINFIELD & SEPTIC TANK
SEP 01 PAID
C .0
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Electrical
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit No.
R
`_ C (' ("?°
Master Permit No. EJ P 9 - 31-
Owner's Name (Fee Simple Titleholder)Po y,C v 1 weiv %foe Phone # 305 7/6 5 7 Z
Owner's Address / 70/ / St & 3 9 !-f
City / "a„-r7 State '9- /
Tenant/Lessee Name
$ Value of Work For this Permit
Zip 7 7) � I
Phone #
Mechanical Roofing
Job Address (where the work is being done) / 00/ ,g/ 5 ('a /J
City Miami Shores Village County Miami -Dade Zip
is Building Historically Designated YES NO
Contractor's Company Name .s 4 p,a1 -- ,5.ep f 4 7 .4/ Phone # '3 05 j 7 9-D a & 2
Contractor's Address 7 7 D / L/ / - / a 14- e
City / � / �e * `j State Zip D / ¢
Qualifier 1,-..R — 2 e r rj
State Certificate or Registration No. 5" �' 0 0 7'2 2.. Certificate of Competency No.
Architect/Engineer's Name (if applicable) Phone #
Square Footage Of Work: 7/ y y
Type of Work: ❑Addition ❑Alteration Iew ❑ Repair/Replace
❑Demolition
Describe Work: 101" / ; / ,S; `-1"q" PL- k
17 S °-- 1
.0 *
Total Fee Now Due $ 3/0.
(Continued on opposite side)
ik , 1 **************** * * * * * * * * * * * * * * * * * * * * * * * * * * * **
# 5) 1
Submittal Fee $ Permit Fee $ ,; )!1
3
Notary $ Training/Education Fee $ O. b
Scanning.$ '� Radon $
Code Enforcement $ Structural Plan Review. $ •
CCF$ o ? ,
CO /CC
Technology Fee $ D • �5
Zoning - — Bond $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all
applicable laws regulating constriction and zoning.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant mush
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature Signature
Owner or Agent
The foregoing instrument was acknowledged before me this
day of , 20_, by
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC: N
Sign: Sign:
Print:
Print: M Commiss on Expires:
Commission Expires: y
Chc 05/13/03
tractor
The foregoin instrument was acknowledge before me s —
day of , 20 by `/C)
who is personally known to me or who has
a ide .ficatiCo0 � 5 l an oath.
NOTARY PUBLIC: go0 co "1P°.
.. =iii.. c
o
_ =T
* * * * * * **
* * * * * * * **
* * * * * * * * * * * * * * * * * * * * * * * * * * * ** ** ** ************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED B jL `/ Plans Examiner
Engineer
Zoning
CONSTRUCTION PERMIT FOR:
[ X ]New System [ ]Existing System [ )Holding Tank [ ] Innovative Other
[ ]Repair [ )Abandonment [ ]Temporary [ IN ]
APPLICANT: Wensjoe, Thomas & Monica AGENT: OWNER,
PROPERTY STREET ADDRESS: 10xx NE 100 St Miami Shores FL 33138
LOT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
BLOCK: SUBDIVISION:
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11- 3205 - 034 -0050 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1050 ]Gallons SEPTIC TANK
A [ 0 ]Gallons
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 )GALLON
D [ 571 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ Y ]STANDARD [ N ] FILLED, ]M0 [ N ]
I CONFIGURATION: [ N ]TRENCH [ Y ]BED [ ]
N
F LOCATION TO BENCHMARK: CL NE 100 St., 8.73' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 32.6 ] [ INCHES ] [ BELOW BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 44.6 ] [ INCHES ] [ BELOW BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 6.0 ]INCHES EXCAVATION REQUIRED: [ 54.1 ] INCHES
OTHER REMARKS:
[SE] Soil replacement required - See attached sheet.
*Install a 1050 gl. C -3 septic tank with its approved outlet filter.
*Install 571 sq.ft. of drainfield.
*Invert elevation to be no less than 5.50' NGVD.
*Bottom elevation to be no less than 5.00' NGVD. INSTALL OF SLIGHTHI,Y LIMITED SOIL
*Install 42" of slightly limited soil under bottom of drainfieP ERBOTTOMOFDRAINIZELD
INVERT ELEVATION
Perimeter of excavation area shall be at least 2 ft. wi e
6 `1
and longer than the proposed absorption bed or drain tr r Ti.OM OF DRAIN SLED ELEVATION j_OO/lJ6
Y .. LUV1L iER OF EXCAVATION AREA SHALL BE
AT LEAST 2.0 FEET 'WIDER AND L ONGER THAN THE
PROPOSED ABSORPTION BED OR DRAIN TRENCH
SPECIFICATIONS BY:Icaza, Carlos
APPROVED BY: Icaza, Carlos
DATE ISSUED: (40 f Z I G3
TITLE:
DH 4016, 03/97 (Obsoletes previous editions wh ch may not be used)
(Stock Number: 5744- 001 - 4016 -0) (ostds_cons 4016 -11
CENTRAX #: 13 -SG -16276
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 03 -1192- -N
g o5/23/o3
ERED /IN SERIES: [Y ]
ERED /IN SERIES: [Y ]
24 HRS # PUMPS[ 0 ]
TITLE: Engineer I Dade CHD
EXPIRATION DATE : 1 21 2 G 6
Page 1 of 2
AGENT: , OWNER
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Wensjoe, Thomas & Monica
BENCHMARK /REFERENCE POINT LOCATION: CL NE 100 St., 8.73' NGVD.
CENTRAX #: 13 -SG -16276
OSTDSNBR : 03- 1192 -N
LOT: BLOCK: SUBDIVISION: ID #: 11- 3205 - 034 -0050
OWNER
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S
MUST PROVTDE REGTSTRATION NUMBER AND STGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALT, ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN:[X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.23 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 400 GALLONS PER DAY [64E -6, TABLE 1]
AUTHORIZED SEWAGE FLOW: 575 GALLONS PER DAY [1500GPD /ACRE OR 2500GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: 1146 SQFT UNOBSTRUCTED AREA REQUIRED: 1143 SQFT
ELEVATION OF PROPOSED SYSTEM SITE IS 32.64 [ INCHES ] [ BELOW ]BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: N/A FT DITCHES /SWALES: N/A 'FT NORMALLY WET? [ ]YES [ X ]NO
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: N/A FT NON - POTABLE: N/A FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 19 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO
10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture Depth
lnvp RN Randy Lnam n to 19,
1fVR- R /2 -WR. Anlitir LimpR 12 tO 72
to
to
to
to
to
to
USDA SOIL SERIES: 42 Udorthents,1
SITE EVALUATED BY: Carlos Icaza
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1) [ostds eval 4015 -3]
10 YEAR FLOODING? [ ]YES [ X ]NO
SITE ELEVATION:
OBSERVED WATER TABLE36.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [PERCHED ]
ESTIMATED WET SEASON WATER TABLE ELEVATION:36.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
invp RN Sanr1yr T.nam n to 15
l OYR- R /2 -WR, flnl i ti r Liman 15 tO
to
to
to
to
to
to
USDA SOIL SERIES: 42 Udorthents,1
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING Replacement/0.70 DEPTH OF EXCAVATION:54.1 INCHES
DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
Soil replacement required - See attached sheet.
DATE: 5/14/03
6 FT NGVD
Page 3 of 3
APPLICANT:
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND. SYSTEM SPECIFICATIONS
' 1 1 ,cs - L\ S
PROPERTY SIZE CONFORMS TO SITE
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
REMARKS /ADDITIONAL CRITERIA:
1 kv.c 31 99 t to r
SITE EVALUATED BY:
• (. 1-
BLOCK: ) /A- SUBDIVISION 0
+"PLAN:
/1 0c
( 3K /REFERENCE POINT LOCATION:
VA ION OF PROPOSED SYSTEM SITE IS ( 1[-N
DH 4015, 10 /96,(Replaces HRS -H -Form 4015 [Page 3] which may be used)
(Stock Number: 5744- 003 - 4015 -1) .
[]
GALLONS
GALLONS
SQFT
[ ] YES [] NO
Munsell # /Color Texture
f c 'r 3/
USDA SOIL SERIES:
t0
t0
Depth
to
to
MSL /NGVD
AGENT:
- "r e
[ Section /Township /Range /Parcel No. or Tax ID H umber]
TO BE COMPLETED BY ENGINEER, 1H TH-UN T EMRLOY.,EE. R,,OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER TGIT PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
NO NET USABLE AREA AVAILABLE:
PER DAY [RESIDENCES -TABLE 1 / HT ER -TABLE 2]
PER DAY [1500 GPD /ACRE OR
UNOBSTRUCTED AREA REQUIRED:
/Fri "[ABOVE e F� O W]
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES /SWALES: � i � 6 FT NORMALLY WET? [ ] YES [ NO
WELLS:
PUBLIC: FT LIMITED USE: u � FT PR ATE: FT NON - POTABLE: q FT
BUILDING FOUNDA I S: FT PROPERTY LINES: r FT' "P'OTABLE WATER LINES: FT
— P
SITE SUBJECT TO FREQUENT FLOODING:
10 YEAR FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE ?' SoIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture
• 3 �c / . � / n , .
Depth
Z) to 1 5
to
to .
to .
to-
s " . " to
-to
to
USDA' SERIES:
OBSERVED WATER TABLE: INCHES [ABOVE /lEILOW] EXISTING GRADE 7,�� I'ik
ESTIMATED WET SEASON WA E TABLE ELEVATION: - %, ‘x INCHES
WATER TABLE VEGETATION: [ ] YES y NO MOTTLING: [ ]
SOIL.TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BE [%
10 YEAR FLOODING? [ ) YES [ NO
SITE ELEVATION: 6 h1 FT MSLNGVD
[ ABOVE /
YES [ ./
DEPTH OF EXCAVATION: 1 1 11 INCHES,,
OTHER(SPECIFY)
[f , .�... C t C s
•
PERMIT #
o • fl 9 1 -W
ACRES
QFT
/REFERENCE POINT
017)11 O. Z.'■
/ APPARENT]
1 EXISTING. GRADE.
EPTH:p/A., INCHES
1
DATE:
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential),
Chapter 10D -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITErr2r SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. [ - 1 SHOT [ - 1 SHOT [ - 1 SHOT
APPLICANT:
AGENT:
PROPERTY ADDRESS: /
LOT: BLOCK: SUBDIVISION:
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
DH 4016,
TANK
[01]
[02 ]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
DRAINFIELD INSTAL T ON /
[10] AREA [1]3[2]C1 3 G SQFT
[11] DISTRIBUTION BOX HEADER
[12] NUMBER OF DRAINLINES j
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER )2,.
[16] ELEVATION [ABOVE'BELO f BM
[17] SYSTEM LOCATION
[18] DOSING PUMPS �[A /l� -4`
[19] AGGREGATE SIZE � ��� C).
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPTH )2 "
FILL
[22 ]
[23 ]
[24 ]
[25]
[26]
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT
CONSTRUCTION INSPECTION
INSTALLATION
TANK SIZE [1] /050 [2]
TANK MATERIAL
OUTLET DEVICE "`
MULTI CHAMBERED 1. ' / N
OUTLET 74 El_ Z d= ,
LEGEND / Vi
WATERTIGHT
LEVEL -ti-- y
DEPTH TO LID
/ EXCAVATION MATERIAL
FILL AMOUNT 9.4 /
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
[
[ ]
[ ]
[ ]
�_ (��
CONSTRUCTIQ�. -E' •VED SAPPROVED] : f n C.�'"� � �1 1:-.) C d CHD DATE: /o - -G `I
FINAL SYSTEM.JAPP ED/ SAPPROVED] : � A c,`- l I 1) CHD DATE : /� Q - G�
10/97 (Previous Editions May Be Used)
AND DISPOSAL SYSTEM
AND FINAL APPROVAL
PERMIT NO .0 3 Q// 7,-2 /\/
DATE PAID: e/'2/ , °r->
FEE PAID: —ZOO
RECEIPT # : ST/d S/
PROPERTY ID # : r � G3 y-00;
SETBACKS
[27] SURFACE WATER FT
[28] DITCHES FT
[29] PRIVATE WELLS FT
[30] PUBLIC WELLS FT
[31] IRRIGATION WELLS FT
[32] POTABLE WATER LINES FT
[33] BUILDING FOUNDATION FT
[34] PROPERTY LINES FT
[35] OTHER FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SIZE PLAN
[46] FINAL SIZE GRADING
[47] CONTRACTOR
[48] OTHER
ABANDONMENT
] [49] TANK PUMPED
] [50] TANK CRUSHED & ` FYLIbED
PT 1: Applicant
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
4/ / m
Page 2 of 3
PERMIT NUMBER:
APPLICANT:
AGENT:
MAILING ADDRESS:
LOT, BLOCK, SUBDIVISION
PROPERTY ID#:
Permit tracking number assigned by CHD.
Property owner's full name.
Property owner's legally authorized representative.
P.O. box or street mailing address for applicant or agent.
Lot, Block and Subdivision for lot or
27 character number for property. (property appraiser ID # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc.)
OUTLET FILTER (manufacturer, make, model)
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
DISTRIBUTION BOX / HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM)
DOSING PUMPS (number installed)
SET BACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS:
CONSTRUCTION APPROVAL:
AS BUILT INSTALLATION SKETCH
Record item number, explanation of violation, and required.
Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Circle approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted unit the CHD has confirmed that building construction and lot grading are in substantial
compliance with plans specifications submitted with permit application.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OF AGGREGATE
[ +] SHOT • H.I. H.I. H.I.
H.I. [ -] SHOT [ -] SHOT [ -] SHOT
ELEVATION