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DRAINFIELDPERMIT # lit» _346. DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID / / 0.`,!',1! ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ 7K aa CONSTRUCTION PERMIT RECEIPT # o:7 7 In S Authority: Chapter 381, FS & Chapter 10D -6, FAC CONSTRUCTION PERMIT FOR: 0J] New System [� Existing System [] Repair [/J] Abandonment APPLICANT: E PROPERTY STREET ADDRESS: J x d / - € 4 r LOT: PROPERTY ID #: 0 T H E R STATE OF FLORIDA BLOCK: a `!., SUBDIVISION: SYSTEM DESIGN AND SPECIFICATIO S i- • [vY11 ,J T [ ] [GALLONS / GPD SEPT1`C TANtC /} j/EROBIC UNI'T A [ ] [GALLONS / GPD] °� :0" N [ ] GALLONS GREASE INTERCEPTOR CAPACITY K [ ] GALLONS PER DOSE DOSING TANK CAPACITY REPAIR D [ ...3 SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ STANDARD [/'j FILLED I CONFIGURATION: [/j] TRENCH [%.11.1 BED F LOCATION OF BENCHMARK: 1 + 1 0 0 L � D FILL REQUIRED: [ 1 al INCHES t Holding Tank [ ] Temporary /Experimental [ Other(Specify) SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -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: APPLICANT AGENT: l / /'"f Ar �. S b c�3 61D 1 7 © , c T [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] TITLE: CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS] DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ] MOUND [ 4 I ELEVATION OF PROPOSED SYSTEM SITE [ r..Jl [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ Ali ]as ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ 3 ` ] INCHES INSTALL 12* CF 1 OAMY COARSE SAND UNDER BOTTOM OF DRAINFIELD SUBMIT BENCHMARK BEFORE INSPLt i TUl! THIS PERMIT IS NOT fQH ADOITION(S) r_i_EVATION - - - 8orr M OF ORAINFIELW t1EvA�1041 _••• SPECIFICATIONS BY: APPROVED BY: t — TITLE: DATE ISSUED: EXPIRATION DATE: THE SE1 T C TM n L BE PUMPED AN) �� �'r EEC11C�1h1 (;:y1E IN 7 �� ,La �C� °�t'N�: Qui1.� 1 HRS -H Form 4016, Mar 92 etes previous editions is may no be u sed ) (Stock Number: 5744 - 001-4016 -- 4O16-0) E. kr. /-/„69 CPHU Page 1 of 2 INSTRUCTIONS: PEP-MIT NUMBER: Permit tracking number assigned by CPHU. APPLICATION FOR: Cliet.:k type of permit, if 'Other" specify type in blank. APPLICANT: Property cwner's full name. TELEPHONE: Telephone number for applicant or agerd. Property c.vner's lcl1y author:2,A representative. MAIL:NO ADDRESS: P.O. bt or street mailir.g address for applicant or agent. LOT, BLOCK, SUBUIVISION or PROPER'i'YlDf: 27 charattter id number for prup.y. (CPIIU may rttquire property aitpraiser ID # or section:township/range(parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Mil:111111110 :tpt..c.ifietaions from Chapter 10D--6, FAC. DRAINFIE.1_0: Alinitomn sperilic.ttions from Chapter 10D-6, FAC. OTI-tER: •Ut. :AS opt.tatir;,...t permit rt.:gulf e. low-k OILIMC flush toilets. variance provisos. SPItClt N3 3Y: at ,r spet.ifi If 6. by a registered engineer must be sealed. ?Plrlf)VE.D BY: CowttY Public ILt-tith UriiL (CPHU) personnel reviewing and approvidg permit. DATE P•iSUED: Date 0..tinit iSAIttli by CTRL. DATE: yeur if attst.m. Les tr_t been installed. Perimt for systru repairs hecome void 90 days from the nat.: tssucd. e: at+ STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT f Permit Application Number Scale: Each block represents 5 feet and 1 inch = 50 feet. By Plan Approved Signature Not Approved -- - •A* PART II - SITE PLAN cd Site Plan submitted ,16.711/4 ALL CHANGES NOST BE APPRQ1/ED;13Y,THE COUNTY HEALTH DEPARTMENT DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used) (Stodc Number 5744-002-4015-6) Date County Health Department Page 2 of 3 Date - PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Job Address /000 /1j a Tax Folio Legal Description Historically Designated: Yes No Owner/Lessee / Tenant C 2/ grim L, Master Permit # f i fl Phone 7a4 - 7-C7 . G 5 y(p Owners Address /000 /� � � � Contracting Co. NR • C 1 /I e if ,D,,.,, -biz-Address < � , �cJ SS# Phon 3 o -i ' S1 7 Sl • Qualifier S T ii State # ig' Municipal # Competency # Ins. Co. / cv-i 00E s y3.W Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRIC : P UMBING MECHANICAL ROOFING PAVING FENCE SIGN f WORK DESCRIPTION Square Ft. 36 Signature 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 (IF 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. �U W Nt;1R'S AFFID I certify that e foregoing information is accurate and that all work will be done in compliance with all applicable g onstructi d zo g /' urth- +. ore, I authorize the above -named contractor to d• the work stated. owner and/or C • . President Date STEPHEN E COCKINC State of Florida U Notary as arfWoriQo My Commi'ss on lS ' ..✓ /Qs��G[� Estimated Cost (value) ( a.a 6 : • e of Contractor or Owner- Builder Asa - 7.g- 6 -/0 -6 ot: a '!i NO. EXP. MAR 12002 S ign My C C.C.F. / • 73? NOTARY S /--2 2 / ao -YP Date BOND 00 77 TOTAL DUE 3-�'