9950 NE 4 Ave Rd (4)Type Insp'n
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date Time
Correction ❑
Re- Insp'n Fee ❑
Permit No
Name
1
Address
5 /
Company
Phone # 3P 5 wa 1 ') 5
For Inspector: N
Approved +f"
Type Insp'
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Date Time
Permit No. I/ ' Oo D cg„
`er ) L1
Name 1)
Addre
Company 0 s
Phone #
For Inspector:: D
Approved
Correction ❑
Re- Insp'n Fee ❑
PEIIIVIIT APPLICATION FOR MIAMI SHORES VILLAGE
10050 N:E. 2nd Avenue • Miami Shores, Florida 33138.305- 795 -2204
Date 6 / � Job Address c /�� • /d I `S " 7 Tax Folio
Legal Description ` Historically Designated: Yes No
Owner /Lessee/Tenet
WORK DESCRIPTION:
AINITIMMI1
Owner's Address
Contracting Co.
Qualifier
State # Municipal #
IF THERE IS NO PERMIT PACKAGE ACCESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY,
THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE
BEFORE CALLING FOR ANOTHER INSPECTION.
A Ay/if 6.-
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING
!'dress /9952 / V 1 �
ss# - 17 "JI 2 Phone J " `
Competency # Ins. Co.
(a-cite/4/
Master Permit # — /24/t - 7G ' J-DOot ' w
5 ° 5-7 73— r9‘3
Phone
MECHANICAL ROOFING
Square Ft. Estimated Cost (value) 243
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 ANY ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
Application is herebymade 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 all disciplines.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating construction and zoning. Furthermore, I authorize the above named contractor to do the work stated.
! 1 .
.
an
s
or
ndo President
0 30
•
1 ,
-
r
ure of owner and/or Condo President
otary
to Owne
OFFICIAL NOTARY SEAL
p' PUdei ANGELA M BECKER
COMMISSION NUMBER
. CC786697
O O
MY O Mt S I E ES
FEES: PERMIT V I 4, • - Fv
.c C.C.F
17 a .3 •a5•.SS/6'o
My Commission Ex
APPROVED:
Zoning Building
Mechanical
Plumbing
Signature of Contractor or Owner Builder Date
o)L .. AAa ! i►
My ■ . ary as to c o ntract • co. � � LA M BECKER
Commission Ex pi Y pi ,� � �' coMwss�oN Nut
N, ' in it Q CC786697
7,. N MY COMNMSSION EXP IRES
F OF pL° NOV. 15,2002
' Ob BOND 3W 1 te
TOTAL DUE
Electrical
Structural Engineer
NOTARY
!P
,I CANT
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITESEWAGE DISPOSAL SYSTEM SPECIFICATIONS
SITE EVALUATION AND
PERMIT #
r •
AGENT: I � � r �_ �.r ? ; y ' r- ... ,..1 L ".
•
cvBDZVISION: /'/ ) ' / f /'y - --
/Township /Range /Parcel No. or Tax ID Number]
OR OTHER QUALIFIED PERSON. =- __ENGINEER'S MUST
i BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, WIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL__ COMPLETE ALL ITEMS = = = =__
tOPERTY SIZE CONFORMS TO SITE PLAN: [ I YES ( ] O NET USABLE AREA AVAILABLE$ — ACRES'
)TAL ESTIMA D SEWAGE FLOW: -0!”.) GALLONS ER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
ER DAY (1500 GPD /ACRE OR 2500 GPD /ACRE]
ITHORIZED SEWAGE FLOW: SQFT UNOBSTRUCTED AREA REQUIRED: `-" " SQFT
iOBSTRUCTED AREA AVAILABLE: '.:'L)
EN CHMARK /REF
LEVATION OF
SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSEDSYSTEEMMMTOTTHE FOLLOWING EFEATU ,1d0
H E mitilmum USE:
URFACE WATER: FT
ELLS: PUBLIC: FT LIMITED DITCHES /SWALES: I
FT PRIVATE: sv ^ FT NON-POTABLE: , FT
/ �_:!
PROPERTY LINES: n FT POTABLE WATER LINES: FT
MILDING FOUNDATIONS: FT ( ] YES [;...1 . NO it • .� FT MSL /NGVD
;ITE SUBJECT TO FREQUENT FLOODING: 10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION:
SOIL PROFILE INFORMATION SITE I 4,W' tlp-t„
Devth
to
- to
t0
to
to
to
to
to
to
USDA SOIL SERIES:
OBSERVED '
WATER TABLE: i •w. INCHES (ABOVE /
EB
ESTEIMAI►TED WET SEASON WATER TABLE YEgVA[I ON:
J NO
HIGH WATER•TABLE VEGETATION: ( ]
SOIL TEXTURE /LOADING RATE FOR SYSTEMCSIZI`G: BED
REMARK
DRAINFIELD CRITERIA: ]
R
Color Texture
Muns i
SITE EVALUATED-RD
DH 4015. 10196 (Replaces HRS -H Form 4015 [Page 3] which may be used)
(Stock Number. 5744 -003 - 4015 -1)
10 YEAR FLOODING? ( ] YES (L°•] NO
SOIL PROF: {LE INFORMATION SITE 2
/1 •. to L.
to
to
to
to
to
to
to
BELOW] EXISTING GRADE. TYPE: (PERCHED / APPARENT]
INCHES ( ABOVE / BELOW ] EXISTING GRADE.
( ] YES (p]' DEPTH:
DEPTH OF EXCAVATION:
] OTHER (SPECIFY)
MOTTLING:
(
r 4 ,
j e 1 of 2
INCHES
INCH
DATE: 1 , ._,L12 . 4 ./ �
Page 3 r-
S - le: Each lilock represents 10 feet and 1 inch = 40 feet.
wATi G 1 / 3
5 pS n) i et - Dra
7
Site Plan submitte
Plan Appro ed
By
STATExDF"PLORIDA
DEPARTMENT OF HEALTH
,APPLICATION FOR O■SITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERM!
Permit App lication Number �') ' o
DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number. 5744-002 - 4015 -6)
PART II - SITEPLAN
Not Approved
CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Date q 28 61- •
n H Ith De artm
County p ent
Page 2 of 4
1 of 2
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System [
[ X . ]Repair [ .]Abandonment [
APPLICANT: Carino, Helen
LOT: 1
STATE OF FLORIDA
DEPARTMENT' OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1050
A [ 0
N [ 0
K [ 0
OTHER REMARKS:
DATE ISSUED: 5/1/02
THE SEPTIC TUX SHALL BE PUMPED AND A SOLID
DEFLECTION DEVICE INSTALLED ON THE OUTLET TEE
REPAIR
PROPERTY STREET ADDRESS: 550 NE 101 St Miami FL 33138
BLOCK: 95 SUBDIVISION: Miami Shores
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11- 3206 - 017 -1160 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64.E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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 PROPERTY DEVELOPMENT.
]Gallons SEPTIC TANK
]Gallons
]GALLONS GREASE INTERCEPTOR CAPACITY
]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS
D [ 400 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: ( y ]STANDARD [ N ]FILLED
I CONFIGURATION: [ ]TRENCH [ ]BED
N
F LOCATION TO BENCHMARK: Top of Bottom Floo 10.50' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 0.9 ] [ FEET
E BOTTOM OF DRAINFIELD TO BE [ 2.9 ] [ FEET
L
D FILL REQUIRED: [ 0.0 ]INCHES
THIS PERMIT IS NOT FOR ADDITION (S).
*Existing 1050 gl. septic tank to remain.
*Install 400 sq.ft. of drainfield.
*Invert elevation to be no less than 8.10'. NGVD.
*Bottom elevation to be no less than 7.60' NGVD.
SPECIFICATIONS BY: COCKING, MSTEPHEN
APPROVED BY: Icaza, Carlos
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0) (ostds_cons_4016 -11
CENTRAX #: 13 -SG -12678
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 02 -1284- -R
]Holding Tank [ ] Innovative Other
]Temporary... .[ NA ] . .
AGENT: SR0931119,'COCKING MSTEPHEN
EXCAVATION REQUIRED: [ 24.0 ] INCHES
TITLE:
MULTI - CHAMBERED /IN SERIES: [Y ]
MULTI - CHAMBERED /IN SERIES: [Y ]
@ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
[ N ]MOUND [ N ]
[ N ]
] [ BELOW] BENCHMARK /REFERENCE POINT
] [ BELOW]BENCHMARK /REFERENCE POINT
THIS PERMIT 13 NOT FOFADD i 9! (S)
INVERT ELEV'A'+iO - , O 11/4") —`)
BOTTOM tiF DAAUIFIELD arNATIOR -. -6 b'/�►c�e
TITLE: Engineer I Dade
EXPIRATION DATE: 7/30/02
CHD
Page 1 of 2
• ;
APPLICANT:
AGENT:
PROPERTY ADDRESS:
LOT: BLOCK:
sue: :::::
CHECKED [X] ITEMS ARE N IN COMPLIANCE WITH
Isszamssammimm 'mum
TANK INSTALLATION
[01] TANK SIZE' [1] [
[02] TANK MATERIAL
[03] OUTLET DEVICE � _
[04] MULTI - CHAMBERED [ Y / N
[05] OUTLET FILTER
[06] LEGEND
[07] WATERTIGHT
[08). LEVEL
[09] DEPTH TO LID
l
1
l
l
l
l
l
l
l
]
l
r s's(-) . /
DRAINFIELD INSTALLATION
[ 10) AREA [ 1 ] /R 3GY 2 ] SQFT
[11] DISTRIBUTION BOX HEADER
[11] NUMBER OF DRAINLINES
[13] ,DRAINLINE SEPARATION 3 �.
[,1 DRkINLINE SLOPE
[ '15 ] ,DEPTH OF COVER
[19 *Annum [ABOVfLBELOWj BM
[17] SYSTEM LOCATION 30 °'
[18] DOSING PUMPS // ✓ i
[19] AGGREGATE SIZE,-
[20] AGGREGATE EXCESSIVE F
[21] AGGREGATE DEPTH
FILL / EXCAVATION MATERIAL
[22) FILL AMOUNT / 1 2
[23) FILL TEXTURE
[24] EXCAVATION DEPTH
[25) AREA REPLACED
[26] REPLACEMENT MATiRli FL
EXPLANATION OF VIOLATIONS % f t.{
[ )
[
[ l
. rx CONSTR APPRO � /.DPROVED] :
STATE, OF. TDB
DEPAATIVNT g TH
ONSITE SEWAGE TREATMENT AND -- D'IPOSAL BUTE1[
CONSTRUCTION INSPE.CTI'ON l WD4INAL APPROVAL
SUBDIVISION: 271-.c..e
ISAPPROVED]
- t
10 /97
J i
PERMIT NO.0 s / .� �`
DATE PAID: C N
!EE PAID: ";', . +
UCEIPT •' #:
.z PROPERTY ID #:
STATUTE OR RULE AND MUST BE CORRECTED.
, /"Contractor
•
•
= = ==ssx:
SETBACKS /
[47] SURFACE WATER , 1 /1 FT
[28] DITCHES ' FT
[29] PRIVATE WELLS // 1 FT
[30] PUBLIC WELLS /J/ FT
[ 31 IRRIGATION WELLS FT
[32] POTABLE WATER LINES ...4-732 FT
[33] BUILDING FOUNDATION S`" FT
[34] PROPERTY LINES S ti FT
(35] OTHER FT
FILLED / MOUND SYSTEM
[36]-- DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE•AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN u'.. ".
[46] FINAL SITE GRADING
r � t.
(47] CONTRACTOR 7>'2 4. C.
[48] OTHER
ABANDONMENT
[49] TANK PU)I3ED
-] tSO) TANK CROSHED 6 _
` 77
c • DATE ~ 2 .a - 0 )
Pang. 2 of 3
PERMIT NUMBER:
APPLICANT:
AGENT:
MAILING ADDRESS:
LOT, BLOCK, SUBDIVISION
PROPERTY ID#:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model)
LEGEND (manufacturer code)
DRAINFIELD AREA (square:feet)
DISTRIBUTION BOX / HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS:
CONSTRUCTION APPROVAL:
Permit tracking n
Property owners :1 name.
Property owners legally authorized representative.
P.O. box or street mailing address for applicant or agent.
Lot, Block and Subdivision for lot or
27 character number for property. (property appraiser ID # or GIS location)
ber assigned by CHD.
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
AS BUILT INSTALLATION SKETCH
Record item number, explanation of violation, and required
Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Cirde approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted unit the CHD has confirmed thatbuilding construction and lot grading are in substantial
compliance with plans and specifications submitted with the permit application.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OF AGGREGATE
[+] SHOT H.I. H.I. H.I.
H.I. [ -] SHOT [-1 SHOT [ -] SHOT
ELEVATION , • ' , , •
0
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 6/19 /2002
Applicant: HELEN CARINO
Owner: CARINO HELEN
JOB ADDRESS: 550 NE 101 ST
Plumbing Permit
Permit Number: PL2002 -155
Contractor Contractor's Address: P 0 BOX 693239
Local Phone: 305 - 651 -7859
Parcel # 1132060171160
Page 1 of 1
Legal Description: MIAMI SHORES SEC 4 PB 15 -14 LOTS 1 -2 -3 BLK 95 LOT SIZE SITE VALUE
Fees: Description Amount
FEE2002 -3445 Building Fee $80.00
FEE2002- 3446. CCF $1.20
FEE2002 -3447 Notary Fee $5.00
FEE2002- 3448 Buildier's Bond $300.00
Total Fees: $386.20
Total Fees: $386.20
Total Receipts: $386.20
Permit Status: Approved Permit Expiration: 12/16/2002 Construction Value: $2,000.00
Work: TO REPLACE DRAINFIELD
If there is no permit package accessible on the job - site for inspectors to verify, there will be no inspections. Re inspection
fee is $50.00, which must be paid in advance before calling for another inspection.
Signed: (INSPECTOR) BY:
Signed:
This Permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the application herefor in strict compliance with all
ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any plans, drawings, statements or specifications that may have been submitted to
and approved by the proper municipal authorities. This Permit may be revoked at any time if the work is not done in compliance with such ordinances or if the plans are changed without
authorization. A further condition upon which this permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the
ordinances and regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes responsibility for work done
by his agents, servants or employees.
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity
with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work done by either
myself, my agent, serva is or employes.
(Contractor or Builder) BY:
•
- PAY
TO THE
ORDER OF
FOR
.,. „ .aaR -, ,
MR. C'S SEPTIC & DRAIN, INC.
OPERATING ACCOUNT '
P.O. BOX 693239 305- 651 -7859
• MIAMI, FL 33269 -0239
//i/i/7"€' reolf-e
Washington Mutual
Washington Mutual Bank. FA
Momt/1991h Street Financal Center 1119
175 NW. 1 th Street t nr rxx -70x1
Miami, F 3169 2 to Customer 5 Ice
41C 44,
DATE
11'6 05 47 311' 1: 267084 L3 I:38 31110 308 4 2»O"
irMAM
63- 8413/2670
1 $ 77z
• 9 /7° DOLLARS 8
5473
dab an ...ow
The Sunshine State
uceese Woo(
C6 50 -382 -
660 HE 101 % Fl, 33 138-2461 Ft
ORSE
02
M RED
0646 SEX 6-06
� ,,
E7tP ESSp P►„'r_"
� �St1E0 02 09
SSE DRNER
a test me ssed W law
3
Date `? Job Address 53 A/6, /0/ 5 - Tax Folio 1/ J3.Zo C 0/ 7 //G p
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant • CO--//)
Owner's Address � $ S ,J. 6. / / J�
Contracting Co. ! s e
Qualifier J--IP 4 C. es cA k^ SS# Phone Cr/ -• 7J J
a .1 - 1/- Munici al Com eten # State # t.5 "�' 7 p Competency Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION 4. 4 c1._> Oez a{
Square Ft. Estimated Cost (value /5 •
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.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Signatur•, . or Condo President
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
r
APPROVED:
Zoning Building
Mechanical Plumbing
ate
YfriS (.2
Date Notary as to
My Commi
Notary as to Owner and/or Condo President
My Commission Expires:
�pR
OF FICIAL NOTARY SEAL IL Di_ C
? � SCOTT W DAVIS
f; * COMMISSION NUMBER
'III -a Q CC255237
7 , 6 , ' MY COMMISSION EXP.
of A. JAN. 26 1991
FEES: PERMIT.k.3■5Th-O RADON C.C.F. /. O0 NOTARY
ontra
on
Master Permit #
Phone
Address /J'3 f / a /I/ G, 47 4.4 --∎-■
Electrical
Signature of Co wner- Builder
or Owner- Builder
Tres:
• .'figs'C( (b)
3gsLig
3
Date
Date
1
• PAUL MENZEL
Nt7FARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC355625
COMMIS; e L . 14 1
L3G • ov
Engineering
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
•
CONSTRUCTION PERMIT FOR:
[ N New System [/] Existing System [,C.a Holding Tank [jylTemporary /Experimental
[yE] Repair [ x i Abandonment [ Other(Specify)
7_ rYn
APPLICANT: /;;?efJ 1 iU0 AGENT: (!lj
PROPERTY STREET ADDRESS: cCi1 /
LOT: N i 1 - BLOCK: SUBDIVISION:
PROPERTY ID #:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
5
7r
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.
SYSTEM DESIGN AND SPECIF OfiTIONS { �{ n i ` e ik„,
T [1 ALLONS GP ] SEPTIC TANK AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
A [ ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
R [
A TYPE SYSTEM: •
I CONFIGURATION:
N
0
BO 1
T
H
E
R
D•,. , .�..'.na1r3 ^'r•T J s-;e :v: -,:..r ^"v r ?a x T 9. •.O1V
Q T x'v r.'1 �: aJ:.
l
°SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
IMARY DRAINFIELD SYSTEM •
SYSTEM
[ TANDARD [ ] FILLED [ ] MOUND
[ ] TRENCH [ D [ [
SITT N7r 7'3:' y ' F3
Tz;I PE P.1'; * 3.(2- Fell NO Fell ADL .ION
S
E
TITLE:
TITLE:
APPLICANT
AN
THE SEPTIC TANK SHALL BE PUMPED MW A SOLID DEFLECTION DEVICE INSTALLED ON THE OUTLET TEE
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0)
/7 471
,mss
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ .30] [I ES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ / ] (124255 0t] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L �P t t1 es�
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: T Z-4 c
12" OP L CAMP C ARS``.'. SAM
:•
[
71 3° '' —'�'M OF r ,??.T� ", t
EXPIRATION DATE:
CPHU
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION FOR: Check type of permit, if "Other" specify type in blank.
APPLICANT: Property owner's full 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 ID t1 or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1OD-6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D-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 Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPHU.
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.
CONSTRUCTION PERMIT FOR:
[AA New System [ Existing System [,L Holding Tank [/..y Temporary /Experimental
[y ] Repair [ �J Abandonment [,Jj Other(Specify)
!
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:a
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 PERMITT APPLICATION. SUCH
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECI IdATIONS
ar
T [/6"0 ] QG ALLON$2/. G ] EPTIC TAN)) /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
A [ ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D �vV
0
T
H
E
R
DATE ISSUED:
STATE OF FLORIDA
lipPARVIENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
60NSTR,UCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK:
SPECIFICATIONS BY:
APPROVED BY f 0 0
e,J AJo _
RIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ "SANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ .] TRENCH � [ �^ 4..4# D [ ]
. S T
F LOCATION OF BENCHMARK: c
I ELEVATION OF PROPOSED SYSTEM SITE [ 3 U] [I HES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ,C ] (INCHE T] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L 1.-..)
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 4]t pNCHES
SUBDIVISION:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions wh
(Stock Number: 5744 - 001 - 4016 - 0)
AGENT: (OS
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
TITLE:
/ 0gITLE:
INSTALLERFCONTRACTOR
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
THE SEPTIC Mil °! D= PUNTED AND A SOLID
"■ tarin{,4 DEVICE INSTf(Ffl ON NE OUTLET TEE
h ma not be used)
i-fc /Oi's-
' / /Nt1/ Clio/1(S 1
EXPIRATION DATE:
Syr/
6
-z /o
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION FOR: Check type of permit, if Other specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: 2.0. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY 7D(/: 27 character id number for property. (CPHU may require property appraiser ID (/ or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 10D-6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D-6, LAC.
OTHER: Other specifications, such as operating permit requirements, low - volume flush toilets, variance provisos.
SPECIFICATIONS 3Y: Name of individurl providing specifications. If designed by a registered engineer must be sealed.
APPROVED 3Y: County Public Health Unit (CP1 -IU) personnel reviewing and approving permit.
DATE ISSUED: Dute permit is issued by CPHU.
EXPL?.ATION DA"' : On: year from date issued if the systern has not been installed. ?ennits for s} stem repairs become void 90 days from the date
issued.
APPLICANT:
LOT:
PROPERTY ID #:
STATE OF FLORIDA
-DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
.. /, ✓ Lf�-� �U AGENT: 4
BLOCK:
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ]
.
TOTAL ESTIMATED SEWAGE FLOW: 0g+e)
AUTHORIZED SEWAGE FLOW: �sC,
UNOBSTRUCTED AREA AVAILABLE: .r...040—
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
SUBDIVISION:
YES [ ] NO NET USABLE AREA AVAILABLE:
PERMIT 1 C U g T S
[Section /Township /Range /Parcel No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE. REG4STRAT.ION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: 660 SQFT
-
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETB CK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: /aft FT DITCHES /SWALES: /47 FT NORMALLY WET? [ ] YES [
WELLS: PUBLIC: N +Q FT LIMITED USE: "0/04 FT PRIVATE: AAA FT NON - POTABLE: /V,01. FT
BUILDING FOUNDATIONS: fit? FT PROPERTY LINES: 3„5 FT POTABLE WATER LINES: 66 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [14 10 YEAR FLOODING? [ ] [14
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: .FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 1
Munse _ Color Texture
USDA SOIL SERIES:
sic
Depth
/ to /Z "
Ito L
Igto
to
to
to
to
to
to
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:,
DRAINFIEgl CONFIGURATION: [ ] TRENCH VJ BED
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY:
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which
(Stock Number: 5744- 003 - 4015 -1)
)
y not be used)
SOIL PROFILE INFORMATION SITE 2
Munsell Color Texture Depth
SA-
sa.,o -e /IL to 2y
S �-¢ 214 ' � to
to
to
to
to
to
to
USDA SOIL SERIES:
OBSERVED WATER TABLE: 40 INCH ABOVE [BEL¢]] EXISTING GRADE. TYPE :, [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW l EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [NO MOTTLING: ] YES [NO DEPTH: INCHES
[ ] OTHER (SPECIFY)
DEPTH OF EXCAVATION: 4 b INCHES
DATE: i /,AA'-
Page 3 of 3
INSTRUCTIONS:
PERMIT 0: Permit tracking number assigned by CPHU.
APPLICANT: Property owner's full name.
AGENT: "Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY IDN: 27 character number for property. (property cpprcicer TD 0 o: c ctie: tow - :yip /rcetgc /rc,xel number)
PROPERTY SIZE: Check if property size et site conforms to submitted the plan. acce..-a m: ale area 3vci`_ale - area exclusive of
a1! paved areas and prepared rood beds within public rights-of-way o : ; :. , re _ a ^s c::ca:cive of r,3 errs, Ekes,
normally wet drainage ditches, marshes, or other such 1;odiee of crater.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record the estimates sewage flow for iho establishment' from Table i, (:_o-- :ss :dera:_ai), Chapter
iOD -6, FAC. Record <'k3 euLSO:i<. >.c cswcge flow "o: i:a3 L.;r :r :. c z:: _ r ::a: ?a_ (;i5;,Sl rchoxt:,
per day per acre for private water ;applies and 2..5CO I r r' per re Eo; ,; : _'c w t app : r,` c : :,�d : sage Y'low
toes teat equal or exceed i.;ze cais_a_:d sewage flow, the pl :saga:_ :..____ .., d 7_'ed.
Record the square feat of unobstructed available, end t;.e L 2c1.;s' : J a st:se :e c:;; : :_i be c3 least 2
times as large as the drainfield absorption cree and et last 75 area: a' _cbstr slot, meet mirticutut:t
setbacks in Chapter SOD -6, FAC. The unobstructed area ntls ::;e car'iguc zt
BENCHMARK INFORMATION: Record the location of the benchmark. If a.sing c surveyor's :zc :ec:. :7.::rs :,;cord tl'_e CC/"..IL! e"e;vctio.. Record the
elevation of the proposed system site in relation (above or below) to i22e Oenchmcr's.
Record minimum setbacks which can be meet to ell listed features. Actual r.neasureareitts :oust be recorded or 'NA°
for non applicable features. Features on site plan or within 75 feet of the applicant lot visa be measured. The location
of any public drinking well within 200 feet of the applicant's hat ratan also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lois subject to flooding record 10 y.cr Eood elevation for site and
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refined are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA coil textures). Refusals must
be clearly documented. Provide USDA soil series if available, record 'UNK° if the series cannot be determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark 'perched" or °apparent° as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and
historical information. Indicate if there is high water table vegetation present. Indicate if mottling to present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEP'T'H OF EXCAVATION: If applicable record depth of excavation required. aecord °NA° if cat applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. llf other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documentation submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SE'R'E 3
[ +J SHOT: H.I. 11.1. H.I.
H.I. [ -J SHOT [ -J SHOT [ -J SHOT
APPLICATION FOR:
Uyp ] New System [,4/1] Existing System
[./] Repair [,,//► ]
APPLICANT:
AGENT:
MAILING ADDRESS:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO- SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIP ION OR DEED]
LOT: i tj / BLOCK: 'v1/4 SUBDIVISION: DATE =
S1BDS / �53
[Section /Township /Range /Parcel No.] ZONING
PROPERLY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICaTION FOR CONSTRUCTION PERMIT
,Authority: Chapter 381, FS & Chapter 1OD -6, FAC
/4 C,q „✓o
�. C s �
/�d • x 61'32;9
AV
BUILDING INFORMATION [/1 RESIDENTIAL
Unit Type of No. of
No Establishment Bedrooms
3
4
APPLICANT'S SIGNATURE:
W4 ] Holding Tank
Abandonment (,,,p] Other(Specify)
,,oLl
• 6 33265
ACRES [Sqft /43560] PROPERTY WATER SUPPLY:
S co n/. E, /o id-
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4015-1)
[
] COMMERCIAL
Building # Persons
Area Sgft Served
1 57 lc /q /re4: 3 2600 3
2
PERMIT #
.DATE PAID
FEE PAID $
RECEIPT #
Temporary /Experimental
TELEPHONE: „ 2
1
] PRIVATE
f � a .5
Business Activity
For Commercial Only
VA1 Garbage Grinders /Disposals .[1/A] Spas /Hot Tubs i ci Floor /Equipment Drains
Ultra -low Volume Flush Toilets Other (Specify) �►
DATE:
''//6/f
] • PUBLIC
Page 1 of 3
INSTRUCTIONS:
APPLICATION FOR: Check type of permit, if Other specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agents.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: ?.O. box or street, city, state and zip cosh mailing address for applicant or agent.
LOT, BLOCX,
SUBDINiS:ON:
PRO PiE`I Fi EDJO:
PR027..RTY
Lot, block, and subdivision for lot (recorded or unrecorded cubdiviaion). If lot is not En r. recorded aumdivirio:e, c copy of the /et
legal description or deed must be attached.
)A'T3 OF SJBDIJIS ON: Official date of subdivision recorded in county plat books (month /d y /year) or d tot originally recorded. :)ivii3rg an approved
lot into two or more parcels for he purpose of conveying ownership shall be corside.ec r r bdivisic : of tc:.
97 character number for property. (CPHII ray require p cperty rpp ~ice. (1 or sectic:Jtcratin 'pip /ra r,- ; /pence: number.
ber.
Net usable area of property in cars (square footage divided 'sy 63,560 cruet'e feet) oxr.Y.univo of ail pivot:: ao cad prepared roar
beds within public rights -of way or elms^ -Manta crd excivaive of iroc7.7 1, lakea, norm, , :Jet c:rci^r f;: d_tc'• :.z '.rr 2C3, or other
ruck bodies of water. Contiguous unpaved and noncorpccted :toad rights-of-way c-:d cceementa with no cabaurfcer) obstruction
may be included in calculating lot area.
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table EI, Chapter IOD-6, FAC. ;Examples: single !family, single wide -Mobile =home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
3UILDXl: AREA: Total square footage of enclosed habitable area of dwelling snit, excluding garage, ecrport, exterior storage shed, or open or fully
screened patios or decks. Based on outside mecsuremen:_} for each story of struetu-;.
Ii
PERSONS: Number of persons residing, using, or working in establishment. L or rsidee :ic: a'zIcbiiahme 9, perrona :er 'sa&oom ate
assumed.
3US NESS AC" 7..NTTY: L=or commercial applications only. List number of employees, rhia, and ao::rt of c2arction, or e'f?•r : ^!b-=r.ctic* aeuired by
"able H, Chapter 1OD -6, FAO.
FI% 'dTz3y: Mark each listed fixture with number installed or 'NA' if not epplicr.b!e.
Signature of applicant or agent. Date application one &y submiit..d to the C ?:K':J with rpp_oprictc focus earls rtt .citritenta.
1 ';.'A'°. :.1 : ENT. S: A site plan drawn to sonic, chow b07Lneciiea with di d�F :II B , :C °_`ic- a 0:7 " C )ililLi':2ra a Y: rg 9CCIB, recorde6
easements, onbite bwL e r itip l ey; tc?' cc ^_ o'?eria i i L. 10Sa:io , aior.14 of re pa• JO :L, tl::117 Lireincr ;.:e
1 �
E t r'i ".nLe tYTtSr. ..rei:t.0 � . :�. 1 '
- ,.: G.a a O fs -. - . _.' ;_. -�,. t. .et'Ce
:].tape_ pe ;in :'> faC°_itt'ac or _, o.; o. l cG ccer: ) a pea if . ,. _..s_ _yr c'a
v!tulic well within 91C0
c'_`co. pl:- (roriL :.rcca) r'ta ' a.'. r
fi
__C0°
neceasrry C .�..
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number J'4; 2 0 99 7
IATrA
EROCE
Site Plan submitted by:
Plan Approved
By
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744. 002- 4015.6)
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
,/ /D /s -
Not Approved
a DP
�■ /mili1
EN■111•10•1111111111111 MINN 11111$11111,
arl
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
("...
£p/ � ,.� '? te
/ , 0 N k- C a AATI , 4
T o ,✓ cc((JL r / - Y
ar°U4I L,�sf3L�L
TIT
Date
County Public Unit
Page 2 of 3
1
1
(
1
1
1
)
g1E
N
4T
Ay,
•
)
L
15
1
c
tee
(I)
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number (% '(: °' / (
Scale: Each block represents 5 feet and 1 inch = 50 feet. A' /014-
Notes: '?o 0 u.. 4 c�c / / r4,4 it ,,.1 cites."
iii. P lair f �.1
/tee, Ar ,D ri0 .✓ t,[ &W ,
/J a,:
TITL
Site Plan submitted by:
Plan Approved
By
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015 -6)
PART II - SITE PLAN
SIGNATURE
Not Approved
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Date 4.1
County Public Unit
Page 2 of 3
1
f •=1S 7
Permit No
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Tony Carino 550 N.E. 101
Owner's Name and Address - No._
street
- - - -- -- -- _ -- - -- - — _ -- - - - - — tied_ - •-- -_. ._.
Registered Architect and /or Engineer __._ ________ —__ - �------------- ____ -_
Employing Plumber's Name Ro. a Sep ±ic_Tank Co. P .Q ctx 31444 Street__
Location and Legal Description Lot
_ - 'N - . 1 101 street
Street and Number where work is to be performed -No Street.
State work to be performed and purpose of building (By Floors)_______
New Building___ -_- _______-- ........ Remode ling____ ____ ......... ________ Addition- ____ -__ -. Repairs No. of Stories ..... .. .... ...... . • _
Size Septic Tank_
Feet of Drain Tile_
Amount of Permit $._. 4.00
_ Type of Tank_ Capacity Gals.
___Dist. Feet of Tank or Drain Field from Well
Date._ -- 10-2-70
Nature of Water Supply: City- Well.___-_--- __-_ .... _______..... ______—__ __Size of Soakage Pit
(Signed)-
umbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts ' obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida nnanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
(Signed)
Master Plumber.
STATE OF FLORIDA, } gs.
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the _..
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Florida
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspy nn, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA-
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LI ST
1
- -_
CHECK
100,
f •=1S 7
Permit No
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Tony Carino 550 N.E. 101
Owner's Name and Address - No._
street
- - - -- -- -- _ -- - -- - — _ -- - - - - — tied_ - •-- -_. ._.
Registered Architect and /or Engineer __._ ________ —__ - �------------- ____ -_
Employing Plumber's Name Ro. a Sep ±ic_Tank Co. P .Q ctx 31444 Street__
Location and Legal Description Lot
_ - 'N - . 1 101 street
Street and Number where work is to be performed -No Street.
State work to be performed and purpose of building (By Floors)_______
New Building___ -_- _______-- ........ Remode ling____ ____ ......... ________ Addition- ____ -__ -. Repairs No. of Stories ..... .. .... ...... . • _
Size Septic Tank_
Feet of Drain Tile_
Amount of Permit $._. 4.00
_ Type of Tank_ Capacity Gals.
___Dist. Feet of Tank or Drain Field from Well
Date._ -- 10-2-70
Nature of Water Supply: City- Well.___-_--- __-_ .... _______..... ______—__ __Size of Soakage Pit
(Signed)-
umbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts ' obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida nnanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
(Signed)
Master Plumber.
STATE OF FLORIDA, } gs.
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the _..
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
My Commission Expires Notary Public, State of Florida
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspy nn, or faulty
materials and /or workmanship.
BUILDING ❑
ELECTRICAL ❑
PLUMBIN
ROOFING ❑
Owner of
Building
Architect
Contractor . y�
or Builder
Legal Lot
Description
Value of
Address of rr+ Value $
Building
lication
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the app plans,
herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any p
d h s work is t ecinccompliance may such ordinances l or e if the p anapproved re the authorization. A further condition l upon which this perm t
g ore if the of g
gran inn to the d work covered herebycwhetherrrshown builder
the plans or draw gs
above n n the stateme is or specifications o a d that he a sumes respons bitty for k
perta g
done by his agents, servants or employees.
Signed: e + '' l "'. ). .., 1 BY + J
lations
In consideration of the issuance t me of this permit ne e e submitted d to in he h of 1 nances and ami Shores llage.
pertaining thereto and in strict conformity wi th the planns, , drawigs statements or
In accepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE, FLORIDA
DATE
PERMIT N? 15201
Work to be performed under this Permit
1
Subdi-
vision
INSPECTOR
BY
Contractor's
License No
Amt. of QQ
Permit $ 0••••••
AUTHORITY
�`� 195