DRAINFIELDDate
Legal Description
/'Owner J Lessee / Tenant
Owner's Address U 0 c'
Contracting Co.
Qualifier
State 0 fir! w Municipal 0 Competency 0 .7era.r Ins.Co.
Architect /Engineer
Bonding Company
Mortgagor
Permit Type(circle
WORK DESCRIPTION
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 info tion is accurate and that all work will
be done in compliance with all applicable laws regulati co struction and zoning) Furthermore, 1
1
authorize the above -named ,contractor to do the work s tte
d
Signature of owner and /or Condo President
Date:
APPROVED:
P44CATION MIA MI SHORES VILLA
4 Job Address
-
c'h
Bc
e P, L - (
24ot ryas to Owner and /or Condo President
My Co • 'pn Ex- OFFICIAL SEAL
A k1
BILLY C. COWINS
** i " . w .-
; My * Commis Ion Expir
Jan. 2f, 1996
FEES: PENIT -..P RADON C.C.F.
Zoning
Mechanical
SS #7.b - u
SI- Tax Folio
Phone S
6
Address D
Address
Address
Address
—1 �
one): BUILDING ELECTRICAL .UJMBING CHANICAL
ota
Master Permit 0
Phone 'rte)
ROOFING PAVING FENCE SIGN
r
Sig ure of Contractor ox/Owner-Builder
Date.
to Contractor or Owner - Builder
My Co a o
ExPLUFe CIAL SEAL
v BILLY C. COWINS
I
�.ti fl� M Commi slonxres
* *1 . . M'. Jan. 996
• ;Q� F.`0 • Comm. No. CC 171522
NOTARY " -- TOTAL DUE iY'
Fire Other
* *
Electrical
n gineering
LOT:
PROPERTY ID #:
SOIL PROFILE INFORMATION SITE 1
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
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: [,] YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
TOTAL ESTIMATED SEWAGE FLOW: GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 21
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES /SWALES: FT NORMALLY WET? [ ] YES [ ] NO
WELLS: PUBLIC: FT LIMITED USE: _ FT PRIVATE: FT NON- POTABLE: - FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: FT POTABLE WATER LINES: FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [,] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
'tO
to
tW
to
to
to
SITE EVALUATED BY:
MRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 -003- 4015 -9)
AGENTS
PERMIT #
[Section /Township /Range /Parcel No. or Tax ID Number]
10 YEAR FLOODING? [ ] YES [ ] NO
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
to
USDA SOIL SERIES:
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [ ] -NO MOTTLING: [ J YES [ ] NO DEPTH: ez INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: u INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED ( ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:
Page--
•
CONSTRUCTION PERMITFOR:
New System 7 Existing System Holding Tank Temporary/Experimenta
: Repair 1 Abandonment Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
L02: BLOCK: SUBDIVISION:
PROPERTY ID is [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER:
SYSTEM MUST CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS c?E: C PA2
REPA:.R PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISS. ALL, CHER UIS
EXPIRE ONE Y3AR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GLA,ANTE Z SLAL:SFLMORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WE::C1' SERVED AS Z
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERM:: APPCh=Ti.
MODIFICATIONS NAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFICATIONS
T
A
N
X
D " ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R ] SQUARE FEET
A TYPE SYSTEM: [ ] STANDARD
I CONFIGURATION: [ 1 TRENCH
N
F LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES/FT] :ABOVE/BELOW: BENCEMARK/aEFZ,RENCF! P:nENT
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES/FT] iABOVE/BELOW I BENCHMARK/REFERENCI FOINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
0
T
,
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
I 'GALLONS / GPI)) SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI-CEAMBERED/:-%
1 tGALLONS / GPD] CAPACITY MULTI-CHAMBERED/:N SER,h,S: ]
1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY S:NGLa; '.2AN;K: .25Z Gb3IONS]
] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE ] PER 24 ERS NO. 0? %=..MPS '
AGENT:
[OR TAX ID NUMBER]
SYSTEM
[ ] FILLED [ MOUND [
[ ] BED [
TITLE:
HRS-M Form 4016, ::,ar 92 (Obsoletes previous editions which may not be used)
(Stock :',!LITher: 5744-001-4016-0)
PERMIT #
ATE PAID
FEE PAID 0
RECEIPT #
TITLE:
EXP:RATION
if 2
Ch' .. if r tr1:::: ' 13C111 type in
for Epp:ler
ru1212:!?:!!!
Ed- Go: EpplicEnt 0
:711-CCI:c SU3D:VISION or
chc : for amy G o:
:):ESECN AND
S.75,:::::■FECA7ZONS:
s?cc:: from, Chco:or 1FAC.
speci from CaEpter :FAC.
Other spk:cificstions, such as operEting perimit requh toilets, voriEnce provisos.
S:?a*C"..C.A77:CNS 3Y: c: inciEv!Cucl providing specificEtions. :f designe::: must be cezle:l.
P,?? 3Y: Conn:y Health 'Unit (CT..-::j) personnel reviewing
1 l'SSZKED: )Etc per. ir ssued by C-U.
:ElX?ilAT:ON One y. :rur - . ate issued if the system hcs not been inctalle!::. for syste:rr repeirs become void 90 dEyE fror . the eLle
issucE.
APPLICATION FOR:
1 New System
I ; Repair
APPLICANT:
AGENT:
MAILING ADDRESS:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO --SCAL
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE COME.
PROPERTY INFORMATION IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK:
PROPERTY ID #:
PR
PERTY 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
[ `] Existing System (- Holding Tank [f] Temporary /Experimental
NA Abandonment [ '] Other(Specify)
A
BUILDING INFORMATION [ ]/RESIDENTIAL
Unit Type
No Establishment
2
3
j Garbage Grinders /Disposals
[ ] Ultra-low Volume Flush Toilets
APPLICANT'S SIGNATURE:
SUBDIVISION: DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
ACRES [Sift /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
p
No. of
Bedrooms
HRS -H Farm 4015, filar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4015 -1)
[
TELEPHONE:
] COMMERCIAL
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
Building # Persons Business Activity
Area Sgft Served For Commercial Only
] Spas /Hot Tubs [ ] Floor /Equipment: Drains
] Other (Specify)
DATE:
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