Loading...
00-0497-004 A r � ciE ' PERMIT NO. Q D-"O wr• ` _ __`k STATE OF FLORIDA DEPARTMENT',`OF HEALTH DATE PAID: - -O U FEE PAID: _ Z Q .'ONSITE SEWAGE TREATMENT AND 'DISPOSAL •SYSTEM RECEIPT #: Z CONSTRUCTION PERMIT a i CONSTRUCTION PERMIT FOR- [4] New System [�] Existing System [ Holding Tank [N] Innovative I [ ] Repair [ ] Abandonment [ ] Temporary [ ] APPLICANT: 5 a k" C G G` •e L , C' C. PROPERTY ADDRESS: 5 X 5' ' S l / 3 :> LOT: BLOCK: C"4 ✓ SUBDIVISION: [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] 1 PROPERTY ID #: Q 2 G o Q [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065, 1 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. SYSTEM DESIGN AND SPECIFICATIONS d t-er T [�iC1`O ] ALLONS / GPD SEPTIC T /AEROBIC UNIT CAPACITY MIILT2-�ERED IN-SERIES [�C] A [ ] GALLONS / GPD CAPACITY MULTI-CHAMBERED/IN-SERIES [ ] N GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS] K [ -J— ] GALLONS DOSING TANK CAPACITY [ ] GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ] D [ ZI ` ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [Z /T ] SQIIARE FEE SYSTEM A TYPE SYSTEM:` [ STANARD [ FILLED [ ] MOUND I CONFIGdRATION: [ ] TRENCH [ BED [ ] N _ F LOCATION OF BENCHMARK: r 3� t ` ,' �' eS 6 _ I ELEVATION OF PROPOSED SYSTEM SITE [(Q,LO,] INCHESJ'FT] [ABOVE(ZllpELOWy ENCHMARK REFERENCE POINT l E BOTTOM OF DRAINFIELD TO BE [C ,Z U] (INCHES FT] [ABOVE�&ELOWr� ENC EFERENCE POINT D FILL':REQUIRED: [ P"C�'t ] INCHES EXCAVATION REQUIRED• [ ] INCHES I��STE�R Z" OF LOAMY MAOSE GAPED M1 OF T, 1 H r-11ATM,] 11,S U , E ,.� 9 E©TTU! rl": -R Vi z'' a � t: �"=1'.:5'•`-`ti �,;- , F 4 I '�• l I! /,, pit a. s. TltZLE t•-.: -T �K1''.i(2 ��C" 2 � PE IFICATIONS BY: � �, , /' y APPROVED BY: TITLE: r�7 L ' f CHI) IIDA,,TE ISSUED: � 17/d � EXPIRATION DATE: I� 17/0 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