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<br />. .,- <br /> <br />,~----,...,-~~~-'C" <br /> <br />~-, <br /> <br />" <br /> <br /> <br />STATE OF FLORIDA <br />DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES <br />ONSITE SEWAGE DISPOSAL SYSTEM <br />CONSTRUCTION INSPECTION AND FINAL APPROVAL <br />Authority: Chapter ,381, FS & Chapter 10D-6, FAC <br /> <br />PERMIT II <br />RECEIPT # <br />FEE PAI:O <br />DATE PAID <br /> <br /><;' .:: <br />, f <br /> <br />.' 'YC/ <br /> <br />$ <br /> <br />APPLICANT: <br /> <br />AGENT: k"-,.' <",__ <br /> <br />, - Ie <br /> <br />PROPERTY STREET ADDRESS: ~ <br /> <br />'-. , 7<.,' <br /> <br />/ ' <br />[-- "- <br /> <br />- \ <br /> <br />LOT: <br /> <br />. / t... <br /> <br />BLOCK: <br /> <br />!~.' <br /> <br />SUBDIVISION: <br /> <br />Ii k <br /> <br />i c." k-: <br /> <br />PROPERTY ID #: <br /> <br />~.. < ~ ,...! <br /> <br />", ~ ({( <br /> <br />( (, {#7.r-. -,/./L./( <br /> <br />[SECTION/TOWNSHIP/RANGE/PARCIE:L NUMBER] <br />[OR TAX ID NUMBER] <br /> <br />-------------------------------------------------------------------------.---------------- <br />-------------------------------------------------------------------------.---------------- <br /> <br />CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 10D-6, FLORIDA ADMINISTRATIVE CODE. <br /> <br />-------------------------------------------------------------------------.---------------- <br />------------------------------------------------------------------------------------------ <br /> <br />riI <br /> <br />TANK INSTALLATION <br />[01] TANK SIZE [1] <br />[02] TANK MATERIAL <br />[03] OUTLET DEVICE <br />[04] MULTI-CHAMBERS <br />[05] LEGEND <br />[06] WATERTIGHT <br />[07] LEVEL <br />[08] DEPTH OF LID <br /> <br />[2] ^_ /6' <br /> <br />SETBACKS <br />[27] SURFACE WATER <br />[28] DITCHES <br />[29] PRIVATE WELLS <br />[30] PUBLIC WELLS <br />[31] IRRIGATION WELLS <br />[32] POTABLE WATER LINES <br />[33] BUILDING FOUND1\TION <br />[34] PROPERTY LINES <br />[35] OTHER <br /> <br /> <br />.... <br />""'t <br /> <br />DRAINFIELD INSTALLATION <br />[09] AREA [1] [2] <br />[10] DISTRIBUTION BOX/HEADER <br />[11] NUMBER OF DRAINLINES <br />[12] DRAINLINE SEPARATION <br />[13] DRAINLINE SLOPE <br />[14] DEPTH OF COVER <br />[15] SYSTEM ELEVATION <br />[16] SYSTEM LOCATION <br />[17] DOSING PUMPS <br />[18] AGGREGATE SIZE <br />[19] AGGREGATE SOURCE <br />[ 20] AGGREGATE WASHED ,rJ <br />[21] AGGREGATE DEPTH <br /> <br />'. <br />/., <br /> <br />SQFT <br /> <br />FILLED/MO~ SYSTEM <br />[36] DRAIr;JhELD COVI~R{ /~: <br />[37] SHOgtDERS <br />I <br />[38] SIJ'PES <br />[39] S'l'ABILI ZATION }u\TERIAL _/ _/ _ <br /> <br />t,' <br />.I <br /> <br />ADDITIONAL INFORMATION <br />[40] UNOBSTRUCTED AREA <br />[41] STORMWATER RUNOFF <br />[42] ALARMS <br />[43] MAINTENANCE AGREEMENT <br />[44] BUILDING AREA <br />[45] PLUMBING FIXTURES <br />[46] FINAL SITE GRADING <br />[47T CONTRACTOR <br />[48] OTHER <br /> <br />FILL/EXCAVA~ION MATERIAL <br />[22] FILL A'MOUNT <br />[23] FILL jrEXTURE <br />[24] EXCAPATION DEPTH A <br />[25] ExcfivATION AREA <br />[26] RE~LACEMENT MATERIAL <br /> <br />i <br />//1 <br /> <br />" <br />ABANDOmstNT <br />[49] T~K PUMPED / / <br />I -- <br />[50] TANK CRUSHED AND FILLED _/_/_ <br /> <br />EXPLANATION OF VIOLATIONS: <br /> <br />b .' . ~. <br /> <br />'.#" <br /> <br />'-'~._ ^t" <br /> <br />! <br /> <br />,"'" <br /> <br />--....-.--..-----..... <br /> <br />CONSTRUCTION i.{~ioI SAPPROVED }.~,::.=,,~ <br /> <br />FINAL SYSTEM (AP-;;;;;-;;)DISAPPROVED] : '_____ <br />-. ~.._-_...---,.-.... <br /> <br />CPHU DATE: <br /> <br />-; <br /> <br />CPHU DATE: <br /> <br />HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) <br />(Stock Number: 5744-002-4016-4) <br /> <br />Page 2 of 2 <br /> <br />BUILDING DEPARTMENT <br />