11-481-001STATE OF FLORIDA
DEPARTMENT OF HEALTH
TM ONSITE.SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICANT:
PERMIT NO, °~
DATE PAID:
FEE PAID:
RECEIPT #:
OR G N-ji
i 3a„
AGENT: ''� "fr _ I�e.l
PROPERTY ADDRESS: "" - -f -
j
LOT: BLOCK. a SUBDIVISION: PROPERTY !D 't"
CHECKED [Xj ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
DRAiNFIELD INSTALLATION �_ ,
TANK INSTALLATION
`
_
AREA 111' " {- [21 'SOFT
[ ] (III
[ I
[a1I
., :' ; ` [2]
TANK SIZE [1]y - ' [
'
] [271
SURFACE WATER
FT
[ 1
[021
TANK MATERIAL S ^' °' — `- ° [
] [281
DITCHES
FT
[ 1
1031
OUTLET DEVICE `.= - - [
] [29)
PRIVATE WELLS
FT
[ 1
[04I
MULTI- CHAMBERED ' -{Y t N.,) I
l = [30I
- ' PUBLIC WELLS
FT
[ 1
[051
OUTLET.FILTER
[311
IRRIGATION WELLS
FT
[ ]
6j
P61
LEGEND 1.-j:
[
] [321
POTABLE WATER LINES =_
FT
[ ]
(07]
WATERTIGHT c e
~ ` " " = [
I 1331
BUILDING FOUNDATION
[ 1
[081
LEVEL
'' I
] [34]
PROPERTY LINES
_FT'
FT
[ 1
[09]
DEPTH TO LID ,. `- .::.- [
) [351
OTHER
FT
DRAiNFIELD INSTALLATION �_ ,
[ ] 1101
_
AREA 111' " {- [21 'SOFT
[ ] (III
DISTRIBUTION BOX HEAPER
[ I (121
NUMBER OF DRAINLINES
[ ] [13]
DRAINLINE SEPARATION •�
[ ] (141
DRAINLINE SLOPE
( 1 [15]
DEPTH OF COVER :` ='
( J [16]
. f• {., ;
ELEVATION [ABOVE!¢ELOIAW] °BM
[ I (17]
SYSTEM LOCATION - -
[ ] [16]
DOSING PUMPS
j ] 1191
AGGREGATE SIZE
[ I [201
AGGREGATE EXCESSIVE FINES
[ j 1211
AGGREGATE DEPTH
FILL 1 EXCAVATION MATERIAL
[ I [22)
FILL AMOUNT
[ 1 1231
FILL TEXTURE
E 1 1241
EXCAVATION DEPTH
[ 1 [251
AREA REPLACED
[ 1 1261
REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS P REMARKS:
[ I
FILLED / MOUND SYSTEM
r
[ I [36] D
DRAINFIELD COVER
[ ] [37] S
SHOULDERS k
k
[ I [491 TANK PUMPED.___/
[ I ... [50]`. :' ,TANK CRUSHED.& FILLED
t CONSTRUCTION [APPROVEDIDISAPPROVEDI' '• =``'�
FINAL SYSTEM [APPROVEDIDISAPPROVEp]:
DH 4016 (Page 2), 14197 (Previous Ed6ons May:&; Used)
Stock Number: 5744 -002 - 4016.4
6029-99tr -90£
i CHD DATE
_ c_
CHD DATE.
PT t; Appii=t
.._._.PT 2: tm"Ier /Cpneraciar
i .. PT 3: Wkfi tg Department
PT 4: Heatlh Department_