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657 NE 92 St (10)Permit No 3 Amount of Permit $ STATE OF FLORIDA, ss. COUNTY OF DADE. My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Date (Signed) • a 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. Owner's Name and Address `'f&off E.f Vl L 4 4 S IA/ c. , No Street M E t 9 2 4r. Registered Architect and /or Engineer py Marta:.::.ta:'b.ng and 'r'_e;i "_i <d, Inc. Employing Plumber's Na No Street Location and Legal Description Lot___ _ 8-19 — Block G 3 SubdivisionsM'I / f1Sl�etle .f sec 3 Street and Number where work is to be performed —No :S .-.- Street__ iv 40 • f _ 4_r., State work to be performed and purpose of building (By Floors) / 2. v IV /T fit fi 7 New Building L ` Remodeling Addition Repairs No. of Stories .2.. Size Septic Tank Type of Tank Capacity Gals Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well Size of Soakage Pit ( Signed) 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 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. Master Plumber. 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 pregoing application, and that he did sign the same, and that all facts • therein by him stated are true. 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 inspection, or faulty materials and /or workinanship• CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT•NS TOTAL FIXTURES 1 4 16 � CONTR. LIST ) 2. / f�' 12 1 2. / Z CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP HEATER DEEP WELL SPRKLR- SYSTEM SWIM•G POOL S Cd, c Ks CONTR. LIST 3 / Z i CHECK Permit No 3 Amount of Permit $ STATE OF FLORIDA, ss. COUNTY OF DADE. My Commission Expires MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Date (Signed) • a 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. Owner's Name and Address `'f&off E.f Vl L 4 4 S IA/ c. , No Street M E t 9 2 4r. Registered Architect and /or Engineer py Marta:.::.ta:'b.ng and 'r'_e;i "_i <d, Inc. Employing Plumber's Na No Street Location and Legal Description Lot___ _ 8-19 — Block G 3 SubdivisionsM'I / f1Sl�etle .f sec 3 Street and Number where work is to be performed —No :S .-.- Street__ iv 40 • f _ 4_r., State work to be performed and purpose of building (By Floors) / 2. v IV /T fit fi 7 New Building L ` Remodeling Addition Repairs No. of Stories .2.. Size Septic Tank Type of Tank Capacity Gals Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well Size of Soakage Pit ( Signed) 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 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. Master Plumber. 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 pregoing application, and that he did sign the same, and that all facts • therein by him stated are true. 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 inspection, or faulty materials and /or workinanship• ' - Permit No._ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made f the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. T s application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the La s 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. Owner's Name and Addre '''e'` -' '' `°` No. �P > _. Stree4#6 7:2 A Registered Architect and /or Engineer / Employing Plumber's Name __,?E / 4/O ! Location and Legal Description Lot ___ /_i__'_ / Q__ __, Q : _ Street and Number where work is to be performed— No.___ o . 1P S r gr Date___ 3_4. Street 4 ( c ` A /d 7 `t� 3 Subdivision 1 ?• JQ_C t' ye State work to be performed and purpose of building (By Floors) New Building Remodeling Addition Repairs No. of Stories Size Septic Tank C Q ` °2 "•// Type of Tank____2�J.:__ ' __SL / 1 '' P../9 C �' Capacity Gals. Feet of Drain Tile" 7,5" 61.50 - Dist. Feet of Tank or Drain Field from Well /7 0 U Nature of Water Supply: City —Well — Size of Soakage Pit /1 __U_� Amount of Permit ( Signed) 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 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) - �- -�. lam+ _ . Master Plumber. STATE OF FLORIDA, I COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared ss. 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 inspection, or faulty materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY Tues U RINALS 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. LIST 1 .� CHECK Permit No._ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made f the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. T s application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the La s 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. Owner's Name and Addre '''e'` -' '' `°` No. �P > _. Stree4#6 7:2 A Registered Architect and /or Engineer / Employing Plumber's Name __,?E / 4/O ! Location and Legal Description Lot ___ /_i__'_ / Q__ __, Q : _ Street and Number where work is to be performed— No.___ o . 1P S r gr Date___ 3_4. Street 4 ( c ` A /d 7 `t� 3 Subdivision 1 ?• JQ_C t' ye State work to be performed and purpose of building (By Floors) New Building Remodeling Addition Repairs No. of Stories Size Septic Tank C Q ` °2 "•// Type of Tank____2�J.:__ ' __SL / 1 '' P../9 C �' Capacity Gals. Feet of Drain Tile" 7,5" 61.50 - Dist. Feet of Tank or Drain Field from Well /7 0 U Nature of Water Supply: City —Well — Size of Soakage Pit /1 __U_� Amount of Permit ( Signed) 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 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) - �- -�. lam+ _ . Master Plumber. STATE OF FLORIDA, I COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared ss. 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 inspection, or faulty materials and /or workmanship. BUILDING ❑ MIAMI SHORES VILLAGE, FLORIDA Date 2 9' 1947 ELECTRICAL ❑ PLUMBING ❑ PERMIT N? 8798 ROO FING . ❑ Owner of Building • Architect Contractor or Builder Legal Lox Description 1 I Bl Address of / 73 ' 447. ez 4 .4v- Building (� f This permit is granted to the contractor or builder named above to construct the building or to install the equipment o- tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will h- plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal at any time if the work is not done in compliance with such ordinances or if the plans are changed without auth' permit is granted is the understanding that the contractor or builder named above assumes the responsibility for regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements sibility for work done by his agents, servants or employees. Signed • 14 ' (INSPECTOR) BY In consideration of the issuance to me of this permit I a ee to perform the work covered hereunder in compli pertaining thereto and in strict conformity with the plans, draw gs, statements or specifications submitted to the prope In accepting this permit I assume responsibility for all work done by either, myself, ri' agent, servant or employee. CONTRACTOR or BUILDER BY Work to be performed under this Permit Contractor's License No o 31 ? Subdi- vision Sq Ft Value of Amount of Project $ I I Permit BUILDING ELECTRICAL PLUMBING ROOFING Owner of Building Legal Lot Description er c : MIAMI SHORES VILLAGE, FLORIDA - DATE 19 V �'' PERMIT ei t_ Architect Contractor 1 or Builder, e 1 t r �� N9 7230 Work to be performed under this Permit 3 r l tT. Contractor's Si Z , Z f License No - t • Subdi- vision Building t' Address of / "` ( Value of Amount of / �f �. Project $ 1 Permit $ 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 applica- tion 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 tle statents or specifirations and that he assumes respon- sibility 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 compllanc with all ordinances aad regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper rides of Miami Shores Village. In as cepting this permit I assume responsibfl ty for all work done by either, myself, my Agent, servant or employee. TRACTOR OR BUILDER, BY } AUTHORITY •uoT' Signed: • INSPECTOR PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date / / - o - o o Job Address - me. 9 a _ Tax Folio 11 0 S' 3 - o J 70 Legal Description SPro RL;S P L V zft 'J t%St cor'Ou Historically Designated: Yes �j' Owner/Lessee / Tenant ,S /fo e r OZw z a Wear C'r, ►.,So - Master Permit # '7 4 a / Owner's Address 6 51 G 1 s7 --cam MS 3;13 a Phone Contracting Co. 31519ilc a C c ou.+S, N C Qualifier T TZ 3" r1 OOJ State # SK ,98 &' 1 8 Municipal # — Competency # Architect/Engineer Address Bon Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL LU MBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION .D P I4 n Ft d e Square Ft 4f 4co 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. � u v J df� C Signature of owner and/or Condo President Date Signature to 0 ssi FEES: PERMIT d/or Condo Pre ires: RADON , 6; Roos r, . fl io ndno Q Address (&arc c c l tJ - 2- 6.42- *2 �3, rat Aro 33167 SS# C 76 -6633 Estimated Cost (value) Ins. Co. 0,1 1'tI t•S tea poo, Not: as to Contractor or Owner - V SF Date M ommission E u � ` ' F Y L1 kR C C.IR11_44. V.7;MAV + N NO. CC71.41: 12/5 it Date C.C.F. ! 0 NOTARY 5 — BOND TOTAL DUE 3 (r? APPROVED: Zoning Building Mechanical Plumbing Engineering Electrical APPLICANT: PROPERTY STREET ADDRESS: LOT: ] ] TYPE SYSTEM: CONFIGURATION: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Authority: Chapter 381, FS & CONSTRUCTION PERMIT FOR: (ij] New System ('•!) Existing System ( ] Repair [ ] Abandonment BLOCK: SUBDIVISION: SYSTEM DESIGN.AND'SRECIFICATIONS D ( PRIMARY DRAINFIELD SYSTEM R [ SYSTEM A [ ] STANDARD [i_J FILLED I [A 1 TRENCH ) ] BED N i F LOCATION OF BENCHMARK: / f 1` , . ;• I ELEVATION OF PROPOSED SYSTEM SITE [ -_Y . ] [INCHES /F ,[ABOVE /Bk40 E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] SQUARE FEET SQUARE FEET L D FILL REQUIRED: [ ti,] INCHES 0 T H E R PERMIT #` DATE PAID /Z 0 ..t.;.,414;;; FEE PAID $ ' O c4 RECEIPT # Chapter 10D -6, FAC I.1 C_ ^ ) ( ;..] Holding Tank ('', Temporary /Experimental [1 ] Other(Specify) AGENT: [OR TAX ID NUMBER] IS It1V BOTTOM ur DRAINF[El SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1] which may be use (. .. (Stock Number: 5744- 001- 4016 -0) Applicant TITLE: TITLE: R- r PERMI PROPERTY ID #: [SECTION /TOWNSHIP /RANGE /PARCEL 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. T [- ] [GALLONS / 6PDJ 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: [j. .] MOUND [ j [ A-] BENCHMARK /REFERENCE BENCHMARK /REFERENCE EXCAVATION REQUIRED: ( INCHES • e t . ■• • EII E g /\ )C. ) \/ EXPIRATION DATE: 1, [1 r - =1 4 l ] POINT POINT } CHD Page 1 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 ID# or section /township /range /parcel number.) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 1OD -6, FAC. DRAINFIELD: Minimum specifications from Chapter 1OD -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. APPLICANT LOT: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS BLOCK: ';'v‘ SUBDIVISION: ' >^ PROPERTY ID ,6 ¢ r r [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 REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: [ ] TOTAL ESTIMATED SEWAGE FLOW: y3�� AUTHORIZED SEWAGE FLOW: UNOBSTRUCTED AREA AVAILABLE: BENCHMARK /REFERENCE POINT LOCATION: ELEVATION OF PROPOSED SYSTEM SITE IS "2.- (INCHES THE MINIMUM SETBACK WHICH SURFACE WATER: t FT WELLS: PUBLIC: i vy"': FT BUILDING FOUNDATIONS: SITE SUBJECT TO FREQUENT FLOODING: 10 YEAR FLOOD ELEVATION FOR SITE: \,- SOIL PROFILE INFORMATION SITE 1 s' A SITE EVALUATED BS(: I DH 4015, 10/96 (Replacee HRS -H Form 4015 [Page 31 whicRfnay be used) (Stock Number: 5744- 003 - 4015 -1) CAN BE MAINTAINED FROM THE DITCHES /SWALES: LIMITED USE: FT FT PROPERTY LINES: Texture Depth �•.. fV.; cw as to to to to to to to to to USDA SOIL SERIES: r,4 YES (/J NO NET USABLE AREA AVAILABLE: x ACRES GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] SQFT UNOBSTRUCTED AREA REQUIRED: S SQFT [ ] YES (X] NO FT MSL /NGVD AGENT: PERMIT # [ABOVE,411 T BENCHMARK /I RC3 POINT PROPOSED SYSTEM TO THE FOLLOWING FEATURES: C M. FT NORMALLY WET? [ ] YES 0.9 NO PRIVATE: N.\ FT NON - POTABLE: NL', FT G FT POTABLE WATER LINES: c3() FT 10 YEAR FLOODI ? [ ] YES (,k� NO SITE ELEVATION: ! FT /NGVD SOIL PROFILE INFORMATION SITE 2 Munsell JfColor Texture Depth 1 4 F ::.�1 61 1 ` .Nf to --1! t, !( r t0 to to to to to to to USDA s SERIES: C ' t (ay{ OBSERVED WATER TABLE: F _ INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION: �?r INCHES [ ABOVE / stow ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ] YES ( NO MOTTLING: [ ] YES (9 NO DEPTH: NIP INCHES DEPTH OF EXCAVATION: INCHES ] OTHER (SPECIFY) SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: [ ] TRENCH [_/] BED REMARKS/ADDITIONALARITERIA: DATE f zr Page 3 of 3 f.) INSTRUCTIONS: PERMIT NUMBER: Permit tracking number by County Health Department. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number). PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. SEWAGE FLOW: UNOBSTRUCTED AREA: MINIMUM SETBACKS: Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential), Chapter 10D-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter IOD -6, FAC. The unobstructed area must be contiguous to the drainfield. BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the proposed system site in relation (above or below) to the benchmark. Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location 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 flooding record 10 year flood 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 refusal are required. Soil identification will use USDA Soil Classification methodology (Munsell colors and USDA soil 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 is present and depth. SOIL TEXTURE: Record soil texture or loading rate for system sizing. DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable. DRAINFIELD CONFIGURATION: Check drainfield configuration required. If 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 documents submitted. ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS: BENCHMARK SITE 1 SITE 2 SITE 3 [ + ] SHOT H.I. H.1. H.I. H.I. [ - ] SHOT [ - ] SHOT [ - ] SHOT AGENT: MAILING ADDRESS: PROPERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: BUILDING INFORMATION Unit Type of No Establishment 1 2 3 4 r APPLICANT'S SIGNATURE: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC APPLICATION FOR: [ ] New System [ ] Existing System [)�] Repair [ ] Abandonment APPLICANT: mot'. dj t ��' • ;fit) vj `: j\,.:.' 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 DESCRIPTION OR DEED] LOT: BLOCK: SUBDIVISIONY j,,tiy ( t dr( t . DATE OF SUBDIVISION: PROPERTY ID #: �'�� � �+�f. � ), _ [Section /Township /Range /Parcel No.] ZONING: PROPERTY SIZE: : : )- ACRES [Sgft /43560] w/ V ( • ] RESIDENTIAL [ ] COMMERCIAL No. of Building # Persons Bedrooms Area Sgft Served k ' [ ] Garbage Grinders /Disposals [ J Ultra -low Volume Flush Toilets DH 4015, 10/96 (Replaces HRS -H Form 4015 ]Page 1] which may be used) (Stock Number: 5744 - 001 - 4015 -1) ] Holding Tank [ ] Temporary /Experimental ] Other(Specify) • ?. p 3n- TELEPHONE : / .5t' r ( : " PERMIT # DATE PAID FEE PAID $ RECEIPT # `3i, > Dr >;v DATE: PROPERTY WATER SUPPLY: [ ] PRIVATE Business Activity For Commercial Onlv ( ] Spas /Hot Tubs [ ] Floor /Equipment Drains [ ] Other (Specify) 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 agent. AGENT: Property owner's legally authorized repreeentative. MAILING ADDRESS: P.O. box or street, city, state and zip code mailing address for applicant or agent. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot legal description or deed must be attached. DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing an approved lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot. PROPERTY ID#: 27 character number for property. (Health Department may require property appraiser IDi or section /township /range /parcel number.) PROPERTY SIZE: Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions 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 II, 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. BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully screened patios or decks. Based on outside measurements for each story of structure. N PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are assumed. BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by Table I1, Chapter 1OD -6, FAC. FDCTURES: Mark each listed fixture with number installed or "NA" if not applicable. SIGNATURE: Signature of applicant or agent. Date application on day submitted to Health Department with appropriate tees and attachments. ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residences, a tloor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other features necessary to determine composition and quantity of wastewater. Scale: Each block represents 10 feet and 1 inch = 40 feet. Notes: Site Plan submitted by: Plan Approved By STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number i I ■ I 1 L : ! ' '' ' ' i.:11 L! C-1 t L-i" ) . _ ! ' f y ----- : f ! / I , PART II - SITEPLAN , 4 - 1 i 2,, 1 - ). , . ",:)..•=1" -••• "--= ; 't • 1 1' 1 . 4, Lt." r • ` ' I Not Approved r t -• ---••••• - • _ , 1 1 - i ;,-,,— " , •: .---. , . „ k , 3 i - ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT !t: )(t fl• " ;I 3J Date - County Health Department DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used) Page 2 of 4 (Stock Number: 5744-002-4015-6)