1997 DrainfieldPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address Pll cl N W I11 1EF2(L, Tax Foho r 1- 21 % - 001 - o 3.7 0
LegalDescriptio/n/ Historically Designated: Yes No
Owner/Lessee / Tenant KR W D 1 N 0 Master Permit # y (O a 3
Owners Address 21q N Vq 111 j er-IzAGe Phone +1 S% - 8 s-10
Contracting Co. I.W)J n "
G Arirt,rcc Xol) QVV i l l car fLLl✓ P—T i H I A7%41
Qualifier NNM1S t P-V'Ue SS# 261 - 9� to37SPhone 72-1676
State # O ZS8 36 -9 Municipal #
Archnoct/Engineer
Bonding Company
Mortgagor
Competency# 1284Z Ins. Co. E51F / '�2A UEI E
Permit Type (circle one): BUILDING ELECTRICAL rrUSURNp MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION (K
I
Square Ft '; 700 Estimated Cost (value) -� 1) )O . GO
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY OF YOU INTEND TO OBTAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I
certify that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate
permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accura d that I work will be done in compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above- ed ntra for to work stated.
owner
Notary s to Owner oes:
C=4 President Date Notary to Contractc
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� e �r °G Terra ]. Felder +
+ W Notory Public, 4.rc o(Flori!!a
Commission Yt�.CC 4808U7 •�
i ''l'nr r�°pAMy Commission Expires OZ/1y/99 •;
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FEES: PERMITRADON C.C.F. l NOTARY
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Date
Date
tsar k*' Tema 7. Felder ------
Nmary Public, bate of riodd,
g` CmIaDinien ti:ICC 480807
ov Fld, My Commission&ires 07/16199
I.800.3-MMKY- M& W W S�t M.t _ r„
BOND 3aC?
TOTAL DUE 33 99 • -C)
Zxining Building —7�0 Electrical
Mechanical Plumbing Engineering
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter IOD-6, FAC
CONSTRUCTION PERMIT FOR:
[ ] New System [�, .`} Existing System [!1'j Holding Tank
(' ] Repair [ w. Abandonment �Other(Specify)
APPLICANT: AGENT: L/
PROPERTY STREET ADDRESS: Z
LOT:
BLOCK:
Z SUBDIVISION: IJ
PERMIT # cl/ / `C') T"'
DATE PAID 2 2�/_47
FEE PAID $ C-4 e--D
RECEIPT #
[.-] Temporary/Experimental
PROPERTY ID Z/ 7/ ,,.UU� ��3>C [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER]
J'O [OR TAX ID NUMBER] u
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD-6, FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMITS
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
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.
CAPACITY MULTI-CHAMBERED/IN
SERIES:[ ]
CAPACITY MULTI-CHAMBERED/IN
SERIES:[ J
MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS)
DOSE RATE [ ] PER 24 HRS NO. OF
PUMPS: [ j
SYSTEM DESI_G.N--ANDfSIFICATIONS_
T [ rJ�] -GOONS ' GPDj SEPTIC TANK/AEROBIC UNIT
A [ ] [GALLONS / GPD] ---- ---
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY
D [ � SQUARE FEETIPRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE" -FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED
I CONFIGURATION: [ ] TRENCH [ L]"BED
N
F
I
E
L
D
O
T
H
E
R
LOCATION OF BENCHMARK: 7— .j" C.'
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED: [ ] INCHES
SPECIFICATIONS BY:
[ ] MOUND [ ]
EXCAVATION REQUIRED:
TITLE:
APPROVED BY: TITLE:
DATE ISSUED: "7
INCHES
.1 - _ __.__
of
_ ��- EXPIRATION DATE:
CPHU
HRS-H Form 4016, Mar 92 (Obso(etes previous editions which may not be used) Page 1 of 2
(Stock Number: 5744-001-4016-0)
;tmTit4umhu
P--rMll trj;king :wnliwr assignad by (Till.
-,11,LfCATION FOR:
Check Lypeofpermit, if"Other' specify type in hlank.
APPLICANT:
property owner's fall name.
TELEPHONE:
Telephone number for applicant or agent.
AGENT:
Property owner's legally authorized representative.
MAILING ADDRESS:
P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#:
27 character id number for property. (CPHU may require property appraiser 11) # or section/township/range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK;
Minimum specifications from Chapter I OD-6, FAC.
DRAINFIELD:
Ifinimum specifications from Chapter IOD-6, FAC.
OTHER:
Other specifications, such as operating permit requirement&, 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 Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED:
Date permit is issued by CPHU.
EXPIRATION DATE:
One year from data issued if the system has not been installed. Permits for system repairs become void 90 days 111tarn the date
issued.