93-0835APPLICANT: yf
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
A4r- -t
BLOCK:
SUBDIVISION:
PERMIT # f3-o Ef,
AGENT: ) / -' /45147T4(0'
- [Section /Township /Range /Parcel No. or Tax ID Number?
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 P
TOTAL ESTIMATED SEWAGE FLOW:
o
AUTHORIZED SEWAGE FLOW: .2 <O
UNOBSTRUCTED AREA AVAILABLE: 9 ,
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:
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN'
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE P POSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: /74 FT DITCHES /SWALES: ,ki FT NORMALLY WET? ,(7 YES [ ] tic
WELLS: PUBLIC: J p FT LIMITED USE: FT PRIVATE: FT NON - POTABLE: F`_
BUILDING FOUNDATIONS: FT PROPERTY LINES: C, FT POTABLE WATER LINES: /�') F'
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [, NO 10 YEAR FLOODING? [ ] YES 4] Nc
10 YEAR FLOOD ELEVATION FOR SITE: kL } FT MSL /NGVD SITE ELEVATION: FT MSL /NGVL
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
USDA SOIL SERIES:
to
to 2 -2
to
to
to
to
to
to
to
OBSERVED WATER TABLE, 4'0 INCHES [ABOVE /
ESTIMATED WET SEASON WATER TABLE ELEVATION:
HIGH WATER TABLE VEGETATION: [ ] YES NO
NO
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
L/, ) INCHES [ ABOVE / BELOW ] EXISTING GRADE.
MOTTLING: [ ] YES [X*0 DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: / , 02 DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [4] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY:
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1)
Page 3 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number g
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Notes:
6 72 .06 S'�5
Site Plan Submitte4
Plan Approved
By
SIGNATURE
Not Approved
unty Public Unit
D BY COUNTY PUBLIC HEALTH UNIT
ALL CHANGES MUST BE APPROVE
Tt1LE
Date 3
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
APPLICATION FOR:
[ ] New System [ ] Existing System
V1 Repair [ ] Abandonment
APPLICANT:
AGENT:
'- ® ,g,96tLe
MAILING ADDRESS: /g- `5— c C't2
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ ] Holding Tank [ ] Temporary /Experimental
[ 1 Other(Specify)
TELEPHONE: W‘6"c/s_____.
= _ ----
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT:
PROPERTY ID #:
PROPERTY SIZE:
BLOCK:
SUBDIVISION:
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
ACRES [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE ` \ PUBLIC
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
33/-6
BUILDING INFORMATION
[ ] RESIDENTIAL [ ] COMMERCIAL
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Soft Served For Commercial Onlv
1 sue- i,
//
A�)
2
3
4
[ ] Garbage Grinders /Disposals
[ ] Ultra -low Volume Flush Toilets
[ ] Spas /Hot Tubs [ ] Floor /Equipment Drains
[ ] Other (Specify)
APPLICANT'S SIGNAy J �! DATE: 3-d- - c:_s)
HRS-H Form 4015, Mar 92 (Obsotetes previous editions which may not be used)
(Stock Number: 5744- 001 - 4015 -1)
Page 1 of 3
CONS
[ ]
[]
APPLI
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE'°SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Chapter 381, FS & Chapter 10D -6, FAC
UCTION PERMIT FOR:
[ ] Ekisting System
[ ] Abandonment
ew System
epair
ANT:
HoIding Tank
] Other.(Specify)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ ] Temporary /Experimental
PROPETY STREET ADDRESS:
LOT:
PROPE'TY ID #:
BLOCK:
SUBDIVISION :.
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTE
REPAI
EXPI
PERFO
BASIS
MODIF
MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6, FAC
PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
CE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A
FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH
CATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFICATIONS
T [
A [
N [
K f
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
[
[ ] SQUARE FEET
TY E SYSTEM: [' ] STANDARD
COQ FIGURATION: [ ] TRENCH
] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS PER DOSE ,DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
SYSTEM
[ ] FILLED
BED
LO ATION OF BENCHMARK:
E VATION OF PROPOSED SYSTEM SITE
BO TOM OF DRAINFIELD TO BE [
FILL REQUIRED:
] MOUND [ ]
]
] INCHES
[INCHES /FT] [ABOVE /BELOW] BENCHMARK/REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
SPECI
APPRO
DATE
HRS -H
(Stock
PICATIONS BY:
VED BY:
ISSUED:
TITLE:
TITLE:
orm 4016, Mar 92 (Obsoletes previous editions which may not be used)
Number: 5744 - 001 - 4016 -0)
.BUILDING DEPARTMENT
s/
CPHU
EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION FOR: Check type of permit, if "Other"' specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent:
AGENT: Property owner's legally authon�ed representative.
MAILING ADDRESS: P.O. box or street mailing addriss for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: 27 character id number for pro
rty. (CPHU may require property appraiser ID # or section/township/range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from aapter 10D-6, FAC.
DRAINFIELD: Minimum specifications from apter 10D-6, FAC.
OTHER: Other specifications, such as - rating permit requirements, low - volume flush toilets, variance provisos:
SPECIFICATIONS BY Name of individual providing s ecifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Public Health Unit (CP AU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CP
EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the date
issued.