DRAINFIELDPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 7 );/ ( a Job Address IO/c t/ 6 • .5'3 S . Tax Folio
Legal Description
Owner/Lessee / Tenant /lit t/ ILO J
Owner's Address to /.S 4 f
Contracting Co. /VA- CJ
Square Ft. 30
Historically Designated:
Address
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Qualifier S � 6 • - -lC //� ss#
e -
State # Municipal # Competency #
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION f p
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.
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
truction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Notary as to Owner and/or Co
My Commissio. ' :rh -s:
gnature of owner and/or Condo Presiden
STEPHEN E COCKING
Notary Stets of Florld
Public My Comm. Exp: )1
Comm#: CC68914Q
FEES: PERMIT 6 Oe O 0 RADON
APPROVED:
Zoning Building
Mechanical Plumbing
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Dfite
C.C.F.
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orm0 Ak
otary as o Contrac
My Commission Ex
Phone 315 _N ' p
Estimated Cost (value) r '
ature of Contractor or
ID
or Owner - Builder
Y
O ,PR 1/4_, ANGELA M BECKER
I - ■ COMM}390N NUMBER
C'III'•'►.+ CC766697
Loy cOMMISSIbN EXPIRES
..O NOV. 15 8002
OF
er- Builder
OFFICIAL NOTARY SEAL
V
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ate
3 DO
NOTARY5 0 6 BOND / b /
TOTAL DU) 4 r o�
Electrical
Yes No
Master Permit #
5 2 ,:flJ - 2
Ins. Co.
ate
Structural Engineer
CONSTRUCTION
] New System
] Repair
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS &
PERMIT FQR:
t ' a pJ Existing System
[kil Abandonment
l� { QA - ) -�
PROPERTY STREET ADDRESS:
g o
t �
LOT: 1 ij gLOCK:
PROPERTY ID #: k40 s 3
ALICANT•
SYSTEM DESIGN AND SPECIFICATIONS
T [1 a- ®q [GALLONS / GPD]
A [ 1 [GALLONS / GPD]
L
D FILL REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
].INCHES
SUBDIVISION:
PTIC T19�
101 STANDARD
1 TRENCH
r
[
Chapter 10D -6, FAC
(D olding Tank [temporary /Experimental
[ ther(Specify)
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY
K [ ) GALLONS PER DOSE DOSING TANK CAPACITY
D [�y &J SQRE FEE .PRIMARY DRAINFIELD SYSTEM
R [ ' ] SQUARE FE T
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE [
AGENT:
SYSTEM
FILLED
BED
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3 . i;
vi
0
TITLE:
TITLE:
K /AEROBIC Uri; CAPACITY
I �U
MOUND
V.
PERMIT i C AL 4
DATE PAID ,sp 0 3 oc
FEE PAID $ � (An
RECEIPT #
(
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
B [OR TAX ID NUMBER]
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. DEPARTMENT OF HEALTH 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.
MULTI- CHAMBERED /IN SERIES:[ ]
CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS)
DOSE •RATE [ ] PER 24 HRS NO. OF PUMPS: ( 1
EXCAVATION.REQUIRED: [�0] INCHES •
1
BENCHMARK /REFERENCE POINT
BENCHMARK /REFERENCE POINT
T
H At :�d / 9:7
-mmm ilim L p . r+ _ • ° <
e �
UWts. 6-NRJLL
•
DH 4018, 10/96 (Replaces HRS -H Form 4016 (page 1) which` � j a) " U pp��9 �f ( ��j �LS U / ( a .i
(Stock Number: 5744 - 001 - 4018 -0) A 1>icant U u, F,
EXPIRATION DATE:
;A5
CHD
Paged of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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. (Health Department may require property appraiser 1D# or
section/township/range/parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter I0D -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 Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
PART II - SITE PLAN=
Scale: Each block represents 5 feet and 1 inch = 50 feet.
wd- 6
5
I Nfip
Site Plan sulkitt9
DH 4015, 10/96 (Replaces HRS-H Form 4015 which ma be used)
(Stock Number: 5744- 002 - 4015.6)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER
Permit ��
Permit Application Number 5 J /(
ignatu e
Plan Approved j Not Approved
LBy -� A County Health Department
ALL CHAN ES MUS - BEAPPROVED BY THE COUNTY HEALTH DEPARTMENT
t
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