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08-471-001
STATE OF FLORIDA £^ DEPARTMENT OF HEALTH G ONSITE SEWAGE TREATMENT>AN:D DISPOSAL' SYSTEM r - CONSTRUCTION INSPECTION AND FINAL APPROVAL AGENT: PERMIT.NO/` L DATE PAID: FEE PAID: RECEIPT S: A I CON FINAL SYSTEM [APPROVED /DISAPPROVED): Al DH 4016 (Page 2),10/97 (Previous Editions May ■e Useol) Stock Number: 5744-002.4016-4 e (-V 'I, _- CHD DAT '. PT 1: Applicant PT 2: Installer/Contractor PT 3: {uilring,Depirtment PT 4: Health Department "'Page 2 of 3 Rwreln/ 5 rarw PROPERTY ADDRESS: , t LOT: a PROPERTY•IDBLOCK�._. CHECKED [XJ ITEMS ARE NOT IN -,COMPLIANCE 'WITH 'STATUTE OR RULE AND MUST BE' CORRECTED. TANK INSTALLATION [ 1 1011 TANK SIZE (1 ,7 [2j [ 1 [271 SURFACE WATER FT ( ) [021 TANK MATERIAL [ 1 (281 DITCHES FT ( ] 1031 OUTLET DEVICE ;,z-.-=--•- [ J [29] PRIVATE WELLS FT ( 1 [04] MULTI-CHAMBERED ((yy / N J ( 1 (301 PUBLIC WELLS FT FT ( ] [051 OUTLET FILTER - fi x ( 1 (31) IRRIGATION WELLS ( ) [06] LEGEN _ , E [ 1 [32] POTABLE WATER LINES — C2� FT [ 1 [071 WATERTIGHT 1 (33) " BUILDING'FOUNDATION --- FT [ 1 [081 LEVEL 1 [341 PROPERTY LINES FT [ 1 [091 DEPTH TO LID .r ' [ 1 (351: OTHER' FT DRAINFIELD INSTALLATION AREA [2]--" SOFT [ 1 FILLED / MOUND''SY'STEM 1361 DRAINFIELD COVER [ 1 (101 ( ] [11] DISTRIBUTION BOX HEADER �� [ 1 (371 SHOULDERS [ 1 (12] NUMBER OF DRAINLINES [ 1 [381 SLOPES; , . ,. ; [ : 1 [131 DRAINLINE SEPARATION„ j [ 1 1391 STABILIZATION [ 1 [141 DRAINLINE SLOPE ( 1 1151 DEPTH OF COVER ADDITIONAL INFORMATION ( ] [16] ELEVATION [ABOVE BM [ ] [40] UNOBSTRUCTED AREA [ 1 [179 SYSTEM LOCATION �. — [ 1 [411 STORMWATER RUNOFF 184' [ ] [189 DOSING PUMPS [ 1 [42 1 ALARM [ ] 1191 AGGRtGATf_SIZE" ' 7 � fr �+ [ ] [431 I MAINTENANCE AGREEMENT [ 1 1201 AGGREGATE EXCESSIVE FINES [ 1 [441 01 DING AREA [ j [45] LOCATION CONFORMS WITH SITE PLAN`;,r^r..k-Ie__ [ j (211 AGGREGATE DEPTH / [ J (461 FINAL SITE GR DING FILL / EXCAVATION MATERIAL ( ] (471 CONT,RACTO -- - _ [ 1 (221 FILL AMOUNT`! '° [ ] (48] OTHER [ 1 [231 FILL TEXTURE [ 1 [241 EXCAVATION DEPTH ABANDONMENT " ' [ 1 [251 AREA REPLACED [ j [49] TANK PUMPED' [ ] 1261 REPLACEMENT MATERIAL [ 1 [50] TANK CRUSHED & FILLED—/—/ EXPLANATION OF VIOLATIONS / REMARKS: -- S7— ' I CON FINAL SYSTEM [APPROVED /DISAPPROVED): Al DH 4016 (Page 2),10/97 (Previous Editions May ■e Useol) Stock Number: 5744-002.4016-4 e (-V 'I, _- CHD DAT '. PT 1: Applicant PT 2: Installer/Contractor PT 3: {uilring,Depirtment PT 4: Health Department "'Page 2 of 3 Rwreln/ 5 rarw