460 NE 93 StP'.-mit 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. G
Owner's Name and Address 1�111L � No._V � �I ! Street.._
Registered Architect and /or Engineer - -_ — - ____ -- - - - -- —
l l gi -_------------------------ ------- -- - -- - --
Employing Plumber's Name_. aagA_N No. .- �._ 0 Street ifi
Location and Legal Description Lot_._ ___._ _.____ _ Block_ Subdivision
Street and Number where work is to be performed —No ZGO A46- .22 ' Street
State work to be performed and purpose of building (By Floors)
New Building -- _ -- Remodeling
Addition
Size Septic Tank - - -- _ _ -__ -_ Type of Tank.
Feet of Drain Vile & _, JA _.2S ist. Feet of Tank or Drain Field from Well .............
_______._
Nature of Water Supply: City — Well._ - -__ _ __-_Size of Soakage Pit
My Commission Expires
Amount of Permit $___.-...... (Signed)_
( Signed
Repairs
Date /
Notary Public, State of Florida
No. of Stories
Capacity Gals.
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contracto •r 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 th site of the wo such public otice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contracto < on ork to • erfo u der)' this permit, as are
licensed by Miami Shores Village.
Master Plumber.
STATE OF FLORIDA, }
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.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOUTS
BATH
TUBS
SHOWERS
LAVA-
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBE
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINK NO
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.
LIST
_
CHECK
P'.-mit 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. G
Owner's Name and Address 1�111L � No._V � �I ! Street.._
Registered Architect and /or Engineer - -_ — - ____ -- - - - -- —
l l gi -_------------------------ ------- -- - -- - --
Employing Plumber's Name_. aagA_N No. .- �._ 0 Street ifi
Location and Legal Description Lot_._ ___._ _.____ _ Block_ Subdivision
Street and Number where work is to be performed —No ZGO A46- .22 ' Street
State work to be performed and purpose of building (By Floors)
New Building -- _ -- Remodeling
Addition
Size Septic Tank - - -- _ _ -__ -_ Type of Tank.
Feet of Drain Vile & _, JA _.2S ist. Feet of Tank or Drain Field from Well .............
_______._
Nature of Water Supply: City — Well._ - -__ _ __-_Size of Soakage Pit
My Commission Expires
Amount of Permit $___.-...... (Signed)_
( Signed
Repairs
Date /
Notary Public, State of Florida
No. of Stories
Capacity Gals.
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contracto •r 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 th site of the wo such public otice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contracto < on ork to • erfo u der)' this permit, as are
licensed by Miami Shores Village.
Master Plumber.
STATE OF FLORIDA, }
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.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by improper notice for inspection, or faulty
materials and /or workmanship.
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 3/ Q Z 6 ff T 1 Job Address ca. ,1‘ f 7 • Tax Folio
Legal Descrip on Historically Designated: Yes No
Owner/Lessee / Tenant rie Master Permit # 11/7 7
Owner's Address S � • 9 7 ;4 Phone 7 S ( 4 3 9 y
Contracting Co. fl* C 1 J X X e_ ,Dre"--i Address /S5) 4 t 4 /J t ' /7 ilia._
Qualifier 51P //G / C . 6chi ss# C57 — 7/5 .
State # Municipal # 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
Square Ft. .34r) Estimated Cost (value) /Ce
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 ;�os;ti • and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Signature of owner and/or Condo President Date
L/
`Notary as to Owner and/or Condo President Date
3A8/ 7
My Commission Expires:
APPROVED:
Zoning Building
Mechanical
•
Signature of Contractor or Owner- Builder
FEES: PERMIT 3‘. RADON C.C.F. NOTARY
Date
Notary as to Contractor or Owner- Builder Date
My Commission Expires:
TOTAL DUE CJ
3t-'p, 6D
CONS RUCTION PERMIT_F9R:
[Af New System [f ] jpxisting System [o Tank [ 4/Temporary/Experimental
[] Repair [Abandonment (MOther(Specify)
APPLICANT: � AGENT: .711"T—
PROPERTY STREET ADDRESS:
LOT : A +LOCK: 520 SUBDIVISION:
PROPERTY ID #:// o w of i [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[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. 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 SPECIFICATIONS
T [ e4:2 ],Q]. / _-GP E PTIC 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 DSE OSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
vet /
D [ P SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ] BED [
F LOCATION OF BENCHMARK: 2C (Qi i a -
I ELEVATION OF PROPOSED SYSTEM SITE [ (5] [INCHES /FT] /BELOW] BENCHMARK /REFERENCE OrNT
E BOTTOM OF DRAINFIELD TO BE [ cr 7_
T] [ ABOVfiELOW f'' BENCHMARK/t ERENCE POINT
L
D FILL REQUIRED: [ ] ..INCHES - EXCAVATION REQUIRED: [ „ y .j INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: °
STATE OF FLORIDA PERMIT # k.
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID ,?.'-'=?
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT RECEIPT # '°"
Authority: Chapter 381, FS & Chapter 10D -6, FAC
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4016-0)
APPLICANT
CPHU
EXPIRATION DATE:
Page 1 of 2
LOT: Li
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
...p4t.t. IVA/ AGENT: A ( Y
BLOCK: SD SUBDIVISION: �' J4
PROPERTY ID #: /1 Zoo /q - 0/ e®
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:
BENCHMARK /REFERENCE POINT LOCATION: ' /rig
ELEVATION OF PROPOSED SYSTEM SITE IS ‘•ez■ [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER:"9 FT DITCHES /SrILES: /6 FT NORMALLY WET? [ ] YES / NO
WELLS: PUBLIC: FT LIMITED N FT PRIVATE: FT NON - POTABLE: ` FT
BUILDING FOUNDATIONS: FT `PROPERTY LINES: � ABLE WATER' LINES: 'r FT
FF
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES (4 NO 10 YEAR FLOODING? [ ] YES [LJ NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: 74f) FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 1
Munsey1 # /Color
C 1 p
USDA SOIL SERIES:
Texture
' ,Depth
Ito ? 7
to
to
to
to
to
to
to
to
SITE EVALUATEDYa-=
HRS -H Form 4015, Mar 92 (Obsoletes previous edit,i4 which no *
(Stock Number: 5744- 003-4015 -1)
[Section /Township /Range /Parcel No. or Tax ID Number]
YES [ ] NO NET USABLE AREA AVAILABLE: . 9 ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 PD /ACRE] '
SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
SOIL PROFILE INFORMATION SITE 2
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [�KBED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
Mun 11 r Color
USDA SOIL SERIES:
ture
De th
/'o 74.
to
to
t0
to
to
to
t0
to
OBSERVED WATER TABLE: ` [ABOVE /-99W] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABL ELEVATION :-- INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [/ NO MOTTLING: [ ] YES [ 010 DEPTH: INCHES
PERMIT # / l'C:d
DEPTH OF EXCAVATION: 344 INCHES
DATE:
e ti
Page 3 of 3
7 1 ' ' 1 1 : ■ 1 ■ 1 1 : : _j_ I ' 1 1 . . 1 J
j
. , : I I_ j
1,....,___, _ , ___:_l_J__ : I I_ . :
_1__ __ : : ___LI 1 . . 1 .__1_1 : : 1 : : 1 1 1m , i111 1 II!
1 1 1 j- _
- 1 1 i
1
Notes'
•
_ I
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
- I 1
1 1 I 1
11
I ' I
, 1 _
...., ,....!-r--,:-.:-/-10----.
1
I
1 :
1
Site PIan Submitted by:
Plan Approved
By
-IRS-H Form 4015, Feb 85 (Obsoletes previous edi)ons which may not be used)
Stock Number: 5744-002-4015-6)
1
: 1
_
PART II SITE PLAN
. 1
1 13°
ez4 k, e, t j TiLtz
a t 5-dt. IC
,
Not Approved
Permit Application Number
1
.:
, _, _
— ) . ' 1 ' ' 1 1 , 1
' : 1 , : . 1 : ' . ■ 1 , .
1 ,
1
6 0.
•
' 14° 0. r)
•
ALL C`H GES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
f TITLE
Date
CountY Public Unit
Page 2 of 3