00-0497-005 A
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU. �•
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CONSTRUCTION
PERMIT FOR: Check type of permit,if"Other"specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent
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AGENT: Property owner's legally authorized representative.
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MAILING ADDRESS: P.O.Box or street mailing address for applicant or agent.
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LOT,BLOCK,SUBDIVISION or
PROPERTY ID#: 27 character id number for property.(CHD may require property appraiser ID#or section/township/range/parcel number)
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SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 64E-6,FAC.
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DRAINFIELD: Minimum specifications from Chapter 64E-6,FAC.
OTHER: Other specifications,such as operating permit requirements,low-volume flush toilets,variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department(CHD)personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CHD
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EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the date
issued.
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