00-0497-002 STATE OF F,T�*7RIDA PERMIT NO. G 4
DEPARTMENT' OF HEALTH DATE PAID:
ONSITE 'SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID ?0 ,
x REC3IPT #:
CONSTRUCTION PERMI '
CONSTRUCTION PERMIT FOR-
New System [N] Existing System [ t� Holding Tank [P Innovative
[1.)] Repair [ 01 Abandonment [�] Temporary [ ]
APPLICANT: J a h GG c Q
PROPERTY ADDRESS: �O 2 /" ! 1 PAY �c J Y " /`'/ / t ' S S
I
LOT: ! BLOCK: SUBDIVISION: 01 // 8,-Y ee"
�
I — �� O Zf`f'/� [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
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PROPERTY ID #: _ 0 00 _ 000 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F�+S. , AND CHAPTER 64E-6, 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.
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SYSTEM DESIGN AND SPECIFICATIONS
T [9 0'J0 ] GALLONS / GPD EPTIC TANK AEROBIC UNIT CAPACITY MULTI-CHAMBERED�IN-SERIES [/ ]
A [ --- ] GALLONS / GPD CAPACITY MULTI-CHAMBERED/IN-SERIES [ ]
N [' --- ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [---" ] GALLONS DOSING TANK CAPACITY [ ] GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ]
f '
D [ Z 1 ] SQUARE FEET PRIMAR�C DRAINFIELD SYSTEM
R [Z ] SQUARE FEE Z-N (� C l ,�,J/ SYSTEM
A TYPE SYSTEM: [ STANARD [ ] FILLED [ ] MOUND
I CONFIGURATION: [ ] TRENCH [ �] BED [ ]
N I, •
F LOCATION OF BENCHMARK: � l L
I t-t ' S ' S ""' ' S + J _
I ELEVATION OF PROPOSED SYSTEM SITE NCHES T] [ABOVE BELOW ��I3CFIMARK REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [Cr/��v] [TN CHES%jT] [ABOV ,$ELOWi) ENCHMARX- REFERENCE POINT
L
D FILL REQUIRED: [ 1J" ] INCHES EXCAVATION REQUIREDD INCHES
,: [ Z ]
0 PHU, I 0j �� � � I c r c, � I��C�, s. 1INSTALL TZ"OF LOAMY CUTISP IPMEM
T Ut�MER BOTTOM OF �rr��lE�a6�L0
H
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E
TF-� l =,,:c .., rL �7/LN.,O)'i (e.E> 9�.,^k. '_J J h 'cr 66aaf;112 Z ZV/ 0
-SPECIFICATIONS BY: J)OT
APPROVED BY: kA TITLE: L' ` �r l 'vr ��° CHD
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DATE ISSIIED: " 12 F/U EXPIRATION DATE: g 2 a O�
DH 4016, 12/99 (Page 1) (Previous Editions May Be Used) Page 1 of 3
pt.1: Health Department
pt.2: Applicant
pt.3: Installer/Contractor
pt.4: Building Department