1999 - SEPTIC/ PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date I t( ( `NA Job Address 100 N t C S ST Tax Folio 1 '32 — 01 Z
Legal Description Lo't ( - 2 t 1.'1 S 5fc,
Owner/Lessee / Tenant P t4 g.1 00 LL
Owner's Address
C o n t r a c t i n g Co. 5PT I G -01∎11 C I t O t S
Qualifier
State #
APPROVED:
Zoning
Mechanical
10p N? OIS S r
TE R.ESi t 5o uom O K‘
5A 0 8b S1 g Municipal #
Historically Designated: Yes No
Master Permit #
Phone
Address QO GoX 3% S fiol -ls1 ti ODD �3O 83
SS# Phone 60S) 6 44 ,33
33
Competency #
Address
Ins. Co.
N 'T S
Architect/Engineer
Bonding Company
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL MB I MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION f N O(Zv F( an
I lam\ �I v1 k
Notary to
1
My Commissi
TERESA J. SOLOMON
MY COMMISSION N CC 854806
EXPIRES: Jul 18, 2003
1.800'3NOTARY Fla. Notary Service 8 Bonding Co.
FEES: PERMIT
mo■• 2
341- TO
RADON
Address
Square Ft.
3
Estimated Cost (value) 1200 ov
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.
My Commission
C.C.F. NOTARY
ider ifr4447444 j Date
No as to Contractor or Owner - Builder Date
ExpiresDFRUAL NOTARY SEAL -
CLADYS J VILLAR
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. 0103
__kW COMMISSION EXP. MAR. 1,2002
BOND
TOTAL DUE
Electrical
Structural Engineer
BUILDING ❑ MIAMI SHORES VILLAGE, FLORIDA
ELECTRICAL ❑
PLUMBING o PERMIT N? 10184
ROOFING ❑
Owner of
Building
Architect
Contractor
or Builder R ,
Legal Lot
Description
Address of }
Building
CONTRACTOR or BUILDER
BI
Work to be performed under this Permit
"
Date 19
Contractor's
License No
Subdi-
vision
Sq. Ft.
Value of * ;« I I Amount of
Project $ 1 r I I 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 the statements or specifications and that he assumes respon-
sibility for work done by his agents, servants or employees.
't
Signed. k (INSPECTOR) BY
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulation,
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
In accepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
BY AUTHORITY
L'UILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building G
Architect
Contractor
or Builder
Legal
Description
MIAMI SHORES VILLAGE. FLORIDA
❑ DATR 195
PERMIT N° 6693 Contractor's
❑ License No. l:°
Work to be performed under this Permit
Lot
CONTRACTOR OR BUILDER
Bl.
Address of
Building
Subdi-
vision
Value of
Project $
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 application
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 cr in the st Cements or specifications and that he assumes responsibility for work
done by his agents, servants or employees.
Signed. BY
INSPECTOR
Amount of
Permit $
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In ac•
-epting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
BY AUTHORITY
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID 8-5 -
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ 7,�,�D
RECEIPT #
CONSTRUCTION PERMIT � ��� j'6 ���1 ® ¢
Authority: Chapter 381, FS & Chapter 10D -6, FAC
CO STRUCTION PERMIT OR:
U ] New System Existing System
] Repair Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
00 Are ter` f
LOT: `] BLOCK: SUBDIVISION:
PROPERTY ID #:i ����� — � � � [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
11J1 [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 SP CI'FICATIONS
T [7j C!, GALLO / GPD] SEPTIC TomIAEROBIC 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: [ ]
D DOC SPU FEET PRIMARY DRAINFIELD SYST,ET
SYSTEM
R [ ] SQUARE FEET
A TYPE SYSTEM: [e-1 STANDARD [ ] FILLED [ ] MOUND [ ]
1 CONFIGURATION: [ ] TRENCH V°`J BED [ ]
N P p�
F LOCATION OF BENCHMARK (2 , ' o P N (9F r) 4 c 6)(5r di ; _ 4 ' 0 r gii :Fp lj i , s /t ' 52
I ELEVATION OF PROPOSED SYSTEM SITE C1 ] [INCH ) [ABOV• BELO BE CHMA NAT.. �`
E BOTTOM OF DRAINFIELD TO BE [ 5f ] INCHES FT] [ABOV BEL BENCHMA t _ r
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [0 0 ] INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
REFERENCE POI
Holding Tank [ ] Temporary /Experimental
] Other(Specify)
TITLE:
HRS Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001 - 4016 -0)
APPLOCART
TITLE:
0?7
PERMIT # $gify47
q ,
AGENT: P f c Co1J ,V6 c[ / o S /G/
l
EXPIRATION DATE:
CPHU
Page 1 of 2
11.\79'17.7:0:."..71CNZ:
?emit ttaz.kinL7 en:17.1; .. .'
1 tjoe of
Property owner's full rarr.P.
7E1..SPHONE: Teh:phona numb: pplicr.:
AGENT: Property owner's let!rtly auto
Iv ADDRESS: P.O. bp,' or Etree. rmidling
BLOCK, SUBDIVISION or
2.1OPERTY DU: 27 character id riurribr for p:o :11.1.:y z:taisr. a) 8 or F2 a
SYSTEM DESIGN AND
SPECIFICATIONS:
Minimum specifications from. '10.3-6, PAC.
:311AINFIELD: Minimum specifications fror. 10 PAC.
OTHER: Other specifications, such as opu per. rcu.me1ts, low-volurne toiluts, vrri.ince
SPECIFICATIC.:NS BY: Name of individual peavidins. a2dc:(7,:atiore.. If by
APPROVED BY: County Public Health Unit (C.71-:: irel reviewing end approviRri
ISSUED: Date perrnit is issued by C-J.
PJ<PTRATION DATE: One yeur from date issd not bee:. instal:ad. `PC'11": 3 c:ya frdm the dat:
issued.
APPLICANT:
0 (-E-Q ► ° ° ° AGENT: Sy -v (G 4 r 10Ups (d5-
SUBDIVISION: Pk‘A.q LSkaas
LOT: �(�1 BLOCK: 21
PROPERTY ID #:0-3
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 tr] NO NET USABLE AREA AVAILABLE: o ry 9 ACRES
TOTAL ESTIMATED SEWAGE FLOW: sob GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: 444k 6 GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: c1 SQFT UNOBSTRUCTED AREA REQUIRED: 4 SQFT
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHE
THE MINIMUM SETBAC WHICH CAN BE MAINTAINED FROM THE
SURFACE WATER: MM FT DITCHES /SWALES:
WELLS: PUBLIC: NA FT LIMITED USE: tiM&t FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES ill NO _;10 YEAR FLOODIN ? J � l NO
10" FLOOD ELEVATION FOR SITE: MSL /NGVD SITE ELEVATION: a 0 FT NGVD
SOIL INFORMATION SITE 1
SITE EVALUATED Y:
STATE OF FLORIDA.. ;!la
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
Munsell Color 0 Depth l � 8 .
U to
to
to
to
to
to
to
to
USDA SOIL SERIE
hIr
[Section /Township /Range /Parcel No. or Tax ID Number]
, ME °1 .' 38)
OBSERVED WATER TABLE: Tr 2.,_ INCHES [ABOVE / BELOW] EXISTING GRADE. TYP PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: 5) INCHES [ ABOVE / EL ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES 7`] NO MOTTLING: [ ] YES NO DEPTH: INCHES
. /`
SOIL TEXTURE OAD RATE FOR SYSTEM SIZING: °8
/
DRAINFIELD C4 .A TION:. [ ] TRENCH 00 BED [ ] OTHER (SPECIFY)
REMARKS /ADDI I NAL CRITERIA:
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be uses)
(Stock Number: 5744- 003 - 4015 -1)
PERMIT #
246 NO'
[ABOVFiakyN] BENCHMARK/ REFE CE T NT
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
(1 , FT NORMALLY WET? [ ] YES (] NO
PRIVATE: ‘ON FT NON- POTABLE: rll A FT
FT POTABLE WATER LINES: VS FT
Munsell ;' Color , Texture
USDA ,SOVW ''
SOIL PROFILE INFORMATION'SITE 2
Depth 6
U to
to
to
to
to
to
to
to
to
IS
"kJ
DEPTH OF EXCAVATION:3) INCHES
DATL
Page 3 of 3
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:
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark reccrd the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the ben Thmark.
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 c n net usable area and water supply
(1 :500 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 10D -6, FAC. The unobstructed area must be contiguous to the drainfield.
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 tie 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 colo •s 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.I. H.1.
H.I. [ - ] SHOT [ - 1 SHOT [ - 1 SHOT
\ By
Scale: Each block represents 5 feet and 1 inch = 50 feet.
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
STATE OF FLORIDA
DEPARTMENT OF HEALTH
PART II SITE PLAN
Signature
• ■
1
1
1 , 1 I , ! ' ' , ' ' I I ! ' ' • , ,
■
) , ■ 1 1 i i t , '
_ _ .
i I
' i Notes: POLL - 100 v (35 Si 53P 6
0 VeCLFLOKu MG
:f
i
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Title
Site Plan submitted
Plan Approved
c4 1/4)0T ( effICMg ,
Not Approved Date 5—of —
A County Health Department
DH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stodc Number: 5744-002-4015-6) Page 2 of 3