1994 SEPTICPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address /00 0 'del 9 ° SST Tax Folio 11 3 /2- c0161 t)
Legal Description Y IY T5 add 1—ot 9 1 +q!'►11 Jh °r4S
Owner / Lessee / Tenant /(&64 /4'' -ie. -e%,--)1 Master Permit #-
Owner's Address / 03Q LAE, 91/45 / - .3% Phone 7s 7 73/ - 7
T"
Contracting Co. 4 00',0 / 2 72 Address bC)a-? S" 3 c 4 - `,
Qualifier ;.% /( l 4,/, / SS4 ‘ - - : �� ' Phone f0) c9.02.3
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING E CTRICAL PLUMBING MECHANICAL ROOFING PAVING PENCE SIGN
WORK DESCRIPTION t,) 2
Square Ft. 3/5' 46 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 information is accurate and that all work will
be done in compliance with all applicable laws regulating construction and zoning. Furthermore, I
author'ze the above.named contractor to do the work stated.
er and /or Condo President
Notary as to Owner and /or Condo Pre ` t
My Commission Expires: IriPtlaNf TOT3IUC, ETAS Cm 71LO IIDA.
1,0i...:.,..) r` %,.... :Ia I Z , . "sib GT,iu"&'Eig.
** * * * * * * * *
FEES: PERMIT 'Pa RADON C.C.F.
APPROVED: Fire Other
Zoning Buildin
Mechanical PlumbinJ
Signature.gf Contractor or e er- Builder
N
My Commission Expires: r!��1
�..-_ CAVID K.4.1
' HOTA.: " \ AMY COMM T X t 3-17-96
� PUBLIC p BONDED BY SERVICE INS CO
Nb. CC17PAM *
NOTARY
or Owner- Builder
**
TOTAL DUE PS 11 %'
lectrical
ngineering
Notes
By
Site Plan Submitted by
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERM,IT.
Permit Application Number /
-(RS-H Form 4015, Fe a 85 (Obsoletes previous editions which may not be used)
Stock Number: 5744-002-4015-6)
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PART II SITE PLAN
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SIGNATURE TITLE
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
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- -
Plan Approved Not Approved Date
County Public Unit
Page 2 of 3
CONSTRUCTION PERMIT FOR:
[ ,) New-System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[A Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -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 r ] [GALLONS / GPD] 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: [ ]
D [ y i] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET
A TYPE SYSTEM: [ ] STANDARD
I CONFIGURATION: [ ] TRENCH
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [-
E BOTTOM OF DRAINFIELD TO BE [ p;!/,
L
D FILL REQUIRED:
0
T
H
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
BLOCK: SUBDIVISION:
AGENT:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 - 0)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM
[ ] FILLED [ ] MOUND [ ]
[ J' BED [ ]
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
INCHES EXCAVATION REQUIRED: [ y ] INCHES
fl
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TITLE:
TITLE: CPHU
EXPIRATION DATE:
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