11-481-003STATE OF FLORIDA PERMIT NO.
DEPARTMENT:70F HEALTH. DATE PAID:
ONSITE SEWAGE-TREAT-MENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION' INSPECTION AND FINAL- APPROVAL RECEIPT ift:
WL
APPLICANT: 7
AGENT:
PROPERTY ADDRESS:
LOT--- BLOCK:— SUBDIVISION:- PROPERTY 10
CHECKED [XI ITEMS ARE - NOT IN COMPLIANCE WITH STATUTE OR RULE AND
MUST BE Ci S L E
TANK INSTALLATION- SETBACKS
(011 TANK SIZE (IJ.1- 121
R71 SURFACE WATER Fr
1 [02] - tTANK MATERIAL t-.
(281 DITCHES F.I.
I [0$1 �_OUTLET DEVICE
1291 PRIVATE WELLS FT
1 -1 [041 'MULTI-CHAMBERED: , '['Y' N J ; [ J 1301 FT
PUBLIC WELLS
1 [051 OUTLET FILTER
1 1311- IRRIGATION WELLS
FT
1 [061 LEGEND 1 [321 POTABLE WATER LINES FT
1 [071 WATERTIGHT t 1 [331 BUILDING FOUNDATION •`
[08) LEVEL- ---------- FT
1 1341 PROPERTY LINES FT
[091 DEPTH TO LID 1 1351 OTHER FT
----i)RAINFIELDrINSTAL-CATION"--"",
I I ., {1 01___.. SOFT
1 1361
- DRAINFIELD COVER
1 1371
I 1'. .-..[1.31.
DRAINLINE, SEPARATION
SLOPES I jr
1 1391
1 71151.
__DEnfi-OF-00VER;
(161
ELEVATION [ABOVE/ L wl BM_
V 7:1
SYSTEM LOCATION
I JIB]
DOSING PUMPS
[191
AGGREGATE SIZE--`-` 11
1 (201
AGGREGATE EXCESSIVE FINES_'
1 [211
AGGREGATE DEPTH
LOCATION CONFORMS WITH SITE PLAN
I L461
FILL I EXCAVATION MATERIAL
r I (22]
FILL AMOUNT
1 [231
FILL TEXTURE-
1 '[241
EXCAVATION DEPTH
1 (251
AREA REPLACED
[251
REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS f REMARKS:
CONSTRUCTION -APF!RqVED/DfSAPPCIOVEDI--
FINAL SYSTEM [APPROVEDIDISAPPROVEDI:
DH 4016 (Page 2),10197 (PrwAous EdWns May Be Used)
Stock Number. 5744-002-4016-4
Z,d 6 . 099-99t-90C
FILLED / MOUND SYSTEM
1 1361
- DRAINFIELD COVER
1 1371
SHOULDERS
1 -138]
SLOPES I jr
1 1391
STABILIZATION
ADDITIONAL
INFORMATION
1 [401
UNOBSTRUCTED AREA
1 [411
STORMWATER RUNOFF
1 [421
ALARMS
1 [431
MAINTENANCE AGREEMENT
1 [4417
BUILDING AREA
1 [451
LOCATION CONFORMS WITH SITE PLAN
I L461
FINAL SITE GRADtNIG
1 [471
CONTRACTOR
1 [481
OTHER
ABANDONMENT
[491
TANK PUMPED
1 (501
TANK CRUSHED & FILLED/—/—
-7 CHD
CHD
PT 1: AprficaM
PT 2, InSlalerICCMwor
PT 3: BOMM Depavmnt
PT 4: Henn oep'arnem
DATE:
DATE--
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