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1205 NE 91 TerrPERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date t' Job Address /..4J /UG• 0 Tax Folio Legal Description Owner / Lessee / Tenant �2 1 K Owner's Address / /146' 9/ »' ir Contracting Co. 22 - 9/e £L /4 /,e1 Address .2,2 ( J44 ( 440. 33e Qualifier 21/66/-e SS# State # Municipal # Competency # Ins.Co. Architect /Engineer Address Bonding Company Address Mortgagor Address Permit Type(circle one): BUILDING ELECTRICAL PLUMBING_ MECHANICAL ROOFING PAVING PENCE SIGN WORK DESCRIPTION )/ 1/t' /6 /) 1 /4tJ Li,477rn/ Square Ft. Estimated Cost(value) � 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 ab -named co ctor to do the work stated. Sign ' ure of owner and/or Condo Pre 'dint Si Sign ture of Co or Owner-Builder / g � or Owner Builder Dat Date: Notary as to Owner and /or Condo President Notar* as to Contractor or Owner- Builder My Commission Expires: My Commission Expires: Mechanical Plumbing) t Master Permit # Phone Phone ** . * * * * * * * * * * * * * * * ** cc FEES: PERMIT A7 RADON C.C.F. NOTARY TOTAL DUES " APPROVED: Fire Other Zoning Building Electrical l 31 ` Engineering CONSTRUCTION PERMIT FOR: [ ] New System [ ] Existing System [> ] Holding Tank [ ] Temporary /Experimental [ -- ] Repair [ ] Abandonment [ ] Other(Specify) APPLICANT: PROPERTY STREET ADDRESS: LOT: PROPERTY ID #: SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ L D FILL REQUIRED: [ ] INCHES 0 T H E R SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC BLOCK: SUBDIVISION: 4 vo AGENT: 3.5© TITLE: HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744 - 001- 4016 EXCAVATION REQUIRED: [ ] INCHES APPLICANT [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] PERMIT # DATE PAID FEE PAID $ RECEIPT # r 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. ] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] ] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS] ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ] D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ -`] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [ ] BED [ N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT TITLE: _ CPHU EXPIRATION DATE: Page 1 of 2 INSTRUCTIONS: PERMIT NUMBER: Permit tracking number assigned by CPHU. APPLICATION FOR: Check type of pennit, 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 stree mailing address for applicant or agent. LOT, BLOCK, SUBDIVISION or PROPERTY ID //: 27 character id number for property. (CPHU may require property appraiser ID fl or section/town6ip /range /parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 10D-6, FAC. DRAINFIELD: Minimum specifications from Chapter IOD-6, FAC. OTHER: Other specifications, such as operating permit requirements, low - volume flush toilets, variance provicoe. 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. Y.i LOT: PROPERTY ID #: STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS BLOCK: TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: TOTAL ESTIMATED SEWAGE FLOW: AUTHORIZED SEWAGE FLOW: UNOBSTRUCTED AREA AVAILABLE: SUBDIVISION: BENCHMARK /REFERENCE POINT LOCATION: T T`w ELEVATION OF PROPOSED SYSTEM SITE IS ;,,0;,w,[INCHES /FT] THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE SURFACE WATER: FT DITCHES /SF,IALES: WELLS: PUBLIC: ) FT LIMITED USE FT BUILDING FOUNDATIONS: FT PROPERTY LINES: SITE SUBJECT TO FREQUENT FLOODING: [ ] YES NO 10 YEAR FLOOD ELEVATION FOR SITE: ii; „114 trr” FT MSL /NGVD SOIL PROFILE INFORMATION SITE 1 Munsell # /Color Texture Depth 7,1" z ; rw, { , 0 to l . r?8 ; :?. 1 A j tom to to to to to to to USDA SOIL SERIES: SITE EVALUATED BY: Lk- 1 +- 1 r ill,' HRS-H Form 4015, Mar 92 (0bssletes previ ss editions which may not be used) (Stock Number: 5744-003-405-1) AGENT: 1 v . PERMIT # 1Section /Township /Range /Parcel No. NET USABLE AREA AVAILABLE: X ACRES [RESIDENCES -TABLE 1 / OTHER -TABLE 2] [1500 GPD /ACRE OR 2500 GPD /ACRE] 3QO SQFT YES ( ] NO GALLONS PER DAY GALLONS PER DAY SQFT UNOBSTRUCTED AREA REQUIRED: E r or Tax ID Number] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT PROPOSED SYSTEM TO THE FOLLOWING FEATURES: FT NORMALLY WET? [ ] YES p4 NO PRIyATE: FT NON - POTABLE: ( d l FT FT POTABLE WATER LINES: FT 10 YEAR FLOODING? pl YES [ ] NO SITE ELEVATION: 6) 1 FT MSL /NGVD SOIL PROFILE INFORMATION SITE 2 Munsell # /Color I USDA SOIL SERIES: Texture Depth IQ to i J to7,: to to to to to to to OBSERVED WATER. TABLE :A ,:,,INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION :4 j?4;, r ;, INCHES ( ABOVE / BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ] YES rx NO MO LING: ( ] YES [ NO DEPTH: Cti i5 , r,c, INCHES SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: 3 INCHES DRAINFIELD CONFIGURATION: [ ] TRENCH [.e3 BED ( ] OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: DATE: rt f/r j� Page 3 of 3 INSTRUOT:ONS: PailMi:li" Permit tracking, number assigited by CP3. A?lreiCANT: Properly owner's full name. AG 1 Property owner'a legally authorized representative. LOT, a..00K, SUBDIVISION: Lot, block, and subdivision for lot. PlIOPE:ILX 27 character number for property. (property appraise: ID 0 or sectiore/townaltipimngeiparce! number) CPERTY SIZE: Check if property size et site conforms to submitted site plan. lllecm-d net usable aree. available - ot area exclusive of all paved areas and prepared road beds within public rights-of-way or easements anti sxclunive of cLeeE17 normally wet drainage ditches, marches, or other such bodies of water. SEWAGE FLOW: UNG7STRUC1ED AREA: Record the square feet of unobstructed tree avcilable and the arricont requires:. '7,J2e'eriLucted be at least times an large as the drainfield absorption area and at least 75 percent of the unobak:..cteer:. crac aeet setbacks in Chapter 100-6, FAC. The unobstructed area must be contiguous to the thmirfield. MINIMUM SETBACKS: Record the estimated sewage flow for the establishment from Tab::: I (residences) or l."able 2 (non-reciaantici), Ciecpter 10D-6, FAC. Record the authorized sewage Low for the bat breed on not area ens: water aelsply (iSCO gallens per day per acre for private water supplies and 2500 god per tare for public water 3:222lies). E cutis0H2,1;f; sewage flow does not equal or exceed the estimated sewage flow, the application must be deried. i3ENCHMARK INFORMATION: Record the location of the benchmark. If using c surveyor's benchmark record the cctoal eveiioo.rorr : the elevation of the proposed system site in relation (above or below) to the bexchmark. Record minimum setbacks which ern be meet 7o all listed features. Actual elensurernents must b recorded or "NA" for non applicable features. Features on site pisn cc withirs 75 feet o: the applicant L.:„7. most be rnscexretle toection of any public drinking well within 200 feet of the applicant's lot must also be verified. FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to fi.m-slizeg re.ccrd 10 yacr floor: elevation for cite and actual site elevation. SOIL ?ROFILE INFORMATION: Two soil profiles within the proposed absorption area too miairnom depth 0;6 feet or 7Zfldfid. Cre. required. Soil identification will use USDA Soil Classification methodology (Muncell colors and USDA coil textures). a'efueals, muat he clearly documented. Provide USDA soil series if available record "UN" if thc series cannot be determined. WATER TABLE: Record the depth of the observed water table at the time of the evaluation. IV:ark 'perched" a: "apparent" ra appropriate. Record the estimated wet season water table elevation based on site evaluation, "USDA coil 7:1 cccl historical information. Indicate if there is high water table vegetation present. Indicate if mottling is preaert am'. SOIL TEXTURE: Record soil texture or loading rate for system sizing. IDE27,11 OF EXCAVATION: If appliqble record depth of excavation required. Record "NA" if not epplicable. DRAIINFIELD CONFIGURATION: Check drainfield configuration required. Nether, specify type. ADD:I CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing re SI.TE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professiorai engineers enuct seri all docurnentatien submitted. ELEVATiON WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT ES: [ DENCHMARX SITE 1 S'..172 2 sr a [ '-j SHCT: 14.1. id.!. H.R. H.R. [-] SHOT ;-] SHOT 1:-] SHOT AGENT: APPLICATION FOR: [ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental Repair [ ] Abandonment [ ] Other(Specify) APPLICANT: 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 1OD -6, FLORIDA ADMINISTRATIVE CODE. PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED] LOT: 1; BLOCK: SUBDIVISION: t DATE OF a -.1 s ' . SUBDIVISION: PROPERTY ID #: 6; > y� [Section /Township/_Range /Parcel No.] ZONING: PROPERTY SIZE: PROPERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: 1 2 3 4 APPLICANT•S SIGNATURE: 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 ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE Unit Type of No. of No Establishment Bedrooms ] Garbage Grinders /Disposals ] Ultra -low Volume Flush Toilets • BUILDING INFORMATION [ ] RESIDENTIAL Building # Persons Area Soft Served NRS -H Form 4015, Mar 92 (Obspletes previous editions which may not be used) (Stock Number: 5744- 001 - 4015-1) PERMIT 1 DATE PAID FEE PAID $ RECEIPT # TELEPHONE: ] COMMERCIAL Business Activity For Commercial Only DATE: 1 PUBLIC ] Spas /Hot Tubs [ ] Floor /Equipment Drains ] Other, (Specify) Page 1 of 3 170S",i7r.:',./C;ONS: LF,:s;;TY: Chr type of permit, if "t..1ther" cpccify "..ype Property owner's full eme. Teiephone number for spplicant c. c,s 'roperty owner's 'icgrliy L,13:!.17.0r1WS; : haft 02 street, chy, str.t: ec.tTn ''`..".3: F 1.7";:;ek, nnd er: t '•. • ".. descEption or dc,:d :Tont, Too s.ttacTicf Ct (Fie of (7 •" So! into 1 . - ::/o or n' ceS Or E113... •••••!;-; :•;;; 27 cl7r.. for proer..7. • : v.et.:2r,r1) LITCE put.Pe. wcy - 33.r!7 - .."3.1 ,d • ir_riuded in crIxsicting To: zrec.. Check private or puYi ;. Street address for property. or lots without an r.!7dr street address, ir-TTcrte .f, Provide detailed instructions to lo t. or att an Cr,: r 73 £ OV.ii.11:'! !at location. NC- 7.NFCT.Z.MATION: Check residentic! or com.mereir.?. . • R..ist type of establisT f.am ?AC. doctor's office. D. '313:2;i1.001VS Count all rooms designed prirlsriTy for Lleeping end 0:10E-1' M:3 cit9f;C:Ctl. occupants. Tfotal footage of enelcu;cd !ta'_ Lina, of 0:fell..i.73 3a.;;;E::, C.:: C2C,":' f:.33 :;creened patios or :leaks. 73.as. on cutsida nnscorenerte for ecek story of st..ectu Number of persons residing, ming, Or wo±i!9 in '::‘ ;For :.",'.7f.:1 2 pe ,:,3ezCtZ."17 rn assumed. 1`..C777.1i7TY: _T.:or commercial app only. ist ;1`.....7111)CY O'',1r.:1 2T2ifis, cd !rouro of c Table II, Chapte: :FAC. iLlark each listed fixture with number installed or "NA" if rot r.ppliceb!. Signature of applicant r agent. ::.r.te appficrtion one clay : to iLe 23.f: Lttac A site plan drew n to scale, , ;!lowirtg Tioti.nricrleu fTin :^ -;, :.:"'n-coo or T easermnts, onsite L,:wagc disoosr.".systen; compen cf F.:1y 1, 17 • Sl..T.11O:';''. features, filled crec::, wat,-;r. c:'in other pertinent faciliti or feat...m:5 an Se:. 1.■CXC.'..".3:1 p:tblic well within 2C0 feel of lot. :For residences, floor (r,:.sicTences; Cr!. • (3,31E1:111711 .' plan ..r foot,;;T: ' :yen, features rtccessn,ry co sT.etermine composi.io:.; r..,T1.;/[1c.tewater. Notes: Site Plan submitted by: Plan Approved By STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number PART II SITE PLAN Scale: Each block represents 5 feet and 1 inch = 50 feet. HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used) (Stock Number. 5744- 002. 4015 -6) .� K w , ) SIGNAIUFtE Not Approved 4 A ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT 300 3II R EI.A Date L jc_ �' 1_►2q . County Public Unit Page 2 of 3