01-0740RSTATE OF FLORIDA.
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM.
CONSTRt7CTION- PERMIT r
CO STRUCTION PERMIT FOR:
f ] New System, Ij
Repair.
APPLICANT:
Existing' System..
Abandonment
L . 4120.4.
DCA
Holding Tank
Temporary
PERMIT NO . . / a & : , .
DATE PAID :. „
FEE PAID: , . 0
RECEIP 6 /00 if, = 9
Innovative
PROPERTY ADDRESS:
LOT: ... BLOCK: / 0 / •SUBDIVISION: f eX7C-1
[SECTION, TOWNSHIP, RANGE, PARCEL NUMiER]
0 (0. / � / 7 of to [OR TAX ID NUMBER]
PROPERTY ID:
SYSTEM; MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OP SECTION 381.0065,
F . S . , AND CHAPTER 64E -6r F;.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM 'COMPLIANCE WITH` OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY:
SYSTEM DESIGN
11
TIONS
T [ `GALLONS / GPD
A [ IC7 Q ] GALLONS / GPD
N [ 1.. GALLONS GREASE INTERCEPTOR CAPACXTY'.
K [. ] GALLONS DOSING TANK .CAPACITY [
AEROBIC UNIT CAPACITY MULTI- CHAMBERED /N- SERIES [ .]
CAPACITY MULTI- CHAMBERED /IN- SERIES [-
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS; @ [ ] DOSES PER 24; HRS # PUMPS [ 1
D [ 0.1,0 O SQUARE FEET PRIMARY DRAINFIELD.' SYSTEM
:
R [ 1 . SQUARE FEET SYSTEM
A TYPE SYSTEM: I°" STANARD [.FILLED [
I CONFIGURATION: [ TRENCH BED;. [:1
F LOCATION OF BENCHMARK:
I, ELEVATION OF PROPOSED SYSTEM SITE [ O.
E BOTTOM OF DRAINFI TO BE [ 7 EXNCHES /FT;
D FILL REQUIRED: [
MOUND:
] INCHES
SPECIFICATIONS BY:
EXCAVATION REQUIRED:
[ABOVE LEL
[ABOVE /B:
1
BENCHMARK /REFERENCE POINT
BENCHMARK /REFERENCE POINT
INCHES
1
ID
NCHMARK UEFA)
INGPECTION
APPROVED BY:
DATE ISSUED:
DE 4016, 12/99 (Page 1)
wrI TITLE:
0orro
TITLE :.
(Previo s Editions May `:Be Used)
EXPIRATION DATE:
K SHALL BE P[ lA"
AGE IH$TALLLE
l'SbLI®
■e•a ent TEE.
yr-
Page 1 of 3
INSTRUCTIONS.
PERMIT NUMBER:
CONSTRUCCION
PERMIT FOR
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
trachitg tamp assigned by CPHU.
Check type 0
Permit, if "Other" spsdfy type in Idle
Property owner's fad tame.
Telephone number for applicant or
Property owner's legally authorized representative.
'P.O. Boa or street ensiling address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID/: 27 character id number for . (CHD may require property appraiser ID # or soctiosetswnsisipiinnesiparcel aaambrr)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
OTHER:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
EXPIRATION DATE:
Minimum spedfieatists from
64E-6, FAC.
Minimum spesifieatioas Nun Chapter f4E-4, FAC.
Other specifications, suck as eperstlig permit requirements, lsw-
Name of individual providing specifications. If deigned by a registered
County Health Department (CHD) persottel reviewing and approving
Date permit is issued by CHD
One year from date issued if the systan has not been installed.
issued.
mss be sealed.
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE. SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
- .Permit Applicationti Number 0 \
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Site Plan Submitted by:- `��-_-
...
Plan Approved
By
Not Approved
Date °
County Public Unit
ALL CHANGES MUST BE APPROVEb BY THE COUNTY PUBLIC HEALTH UNIT,
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 -002- 4015 -6)
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