00-0497-006 _ __` STATE OF FLORIDA
PERMIT NO. OO -�� 74
-' DATE PAID: 3 - a - 00
DEPARTMENT OF HEALTH FEE PAID:._, Q. vv
ONSITE SEWAGE TREATMENT AND 'DISPOSAL SYSTEM RECEIPT
CONSTRUCTION 'PERMIT
C NSTRUCTION PERMIT FOR
[ ] New System [�] Existing System [ E`�] Holding Tank I ] Innovative
[� ] Repair [ Nl Abandonment �) [ N] Temporary I ]
APPLICANT: S Q rri Clr ce L C . C . ! o le c-k
PROPERTY ADDRESS: 6 S X
LOT: BLOCK: 61" SUBDIVISION: �11 (2,, lJG1iS `" e-f,/' �►U/SI�
o Z q - 66,0 -Q(��'J [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
PROPERTY ID #: - ` [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 ,& THIS PROPERTY.
f
SYSTEM DESIGN AND SPECIFICATIONS
T [jU 0 ] GALLONS / GPD SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CHAMBERED/IN-SERIES [ ]
A [ GALLONS / GPD CAPACITY MULTI-CHAMBERED/IN-SERIES I ]
N [ --- ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ -- ] GALLONS DOSING TANK CAPACITY I ] GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ] )
D [ Z 'qi ] SQUARE FEET PRIMAtRY,DRAIN IE D SYSTEM
R [ Z I `� ] SQUARE FEET, 2 '°—c `36_6 1.141 ff �cs SYSTEM
A TYPE SYSTEM: I � STANARD [/] FILLED [ ] MOUND [ ] _
I CONFIGURATION: [ ] TRENCH [ ] BED [ ]
F LOCATION OF BENCHMARK: J S f �� �'_' _ 5' to , E6 S I
I ELEVATION OF PROPOSED SYSTEM SITE [1 ,20 ] [[,INC6IFs$ FT] [ABOV BELOW]�F QE REFERENCE POINT j
E BOTTOM OF DRAINFIELD TO BE [ 6,201 INCHES FT] [ABOVE BELOW BENCHMARr REFERENCE POINT
y� � _ .% _-___
D FILL,'REQUIRED: [I ] INCHES EXCAVATION REQUIRED: [ 7 ] INCHES
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11SPE BY: , ;t�t i TITLE': ts' f
APPROVED BY: f i � � TITLE: �— j / I r !�k'�,/ti) CHD
DATE ISSUED: I EXPIRATION DATE: / l °-
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