DRAINFIELDDate /cy /D /P Job Address
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
g / F. Sys
Tax Folio
Legal Description / Historically Designated: Yes ( l ? /Ae No �� Owner/L essee / Tenant cica a.,-..\ L-ct3 bS - aster Permit # �' 3-/ ` ti
(iunei's Address /Z 8L1 - 1 l S I A -e -1. Phone 7..Sy — 4i 2--
/ /�`1 ?. e J _� /� � n /J
Contracting Co. f � � G � �` r &. 3 Address � / s�� ,,,/ a .2/ /'- .(-� , ?. i
Qualifier S Iii PA' &AJ ev c %C e/ Phone ( oj� C-� 3 - / - /a7
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICA LL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION / %/ �� " ' c_. ,... k
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 dc, the work stated.
Square Ft. � Estimated Cost (value
FEES: PERMIT - RADON
APPROVED:
Zoning Building
Mechanical
Of wner and/o r o o President
7‘
Notary as to Owner ancl/oKtemle&esident ate
My ComfeqnsEPElliff& E COCKING
State of Florida
rubiic My Comm. Exp:08 /04 /0'.
. J Comm#: CC8a9 ie0
2 6
1
ignature of Contractor or Owner - Builder
Notary as to Contractor or Owner - Builder
My Commission Expires:
0 01. OFFICIAL NOTA
. SANDRA It NONTIIL
• ,>, _ rt * COMMISSION NtIMSSn
< CC401261
Q' MY COMMISSION , IrXP,
OF Fo AWL 17 11
C.C.F. /r�) NOTARY S • BOND 3(1-
Electrica',
Date
Date
/(% /u _ -7.7
TOTAL DUE
Engineering
CON TRUCTION PERMIT F
New System V"
[f] Repair
APPLICANT:
7-Th c1../'..6. /tom
PROPERTY ID #: `\
OF FLORIDA
PARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
xisting System [1ding Tank (,G) Temporary /Experimental
Abandonment [ Other(Specify)
X3 5 AGENT: ', C / S ( I
PROPERTY STREET ADDRESS: / L/ /0 e u S e
LOT: N A BLOCK: it/A SUBDIVISION: J
[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 IV THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIFICATIONS
/ /ST [/ GALLONS LGPD]C PTIC TAN$.fAEROBIC 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 [416 SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOU!'D
I CONFIGURAT ;ON: [ ] TRENCH [ (_.}- ED [ [
N L i 1- 7 , y-' -7 ",,r �04
F LOCATION OF BENCHMARK: 1/ S � � "2,— , '/ /CMG I ' � �� N �/ /�� / �'7�
I ELEVATION OF PROPOSED SYSTEM SITE [ g',S] [INCHES /FT] [ABOVE BELOW] BENCHMARK REFERENCE POIN
E BOTTOM OF DRAINFIELD TO BE [ 574 (IJ INCHESjam] [ABO BELO W,].BENCHMA FERENCE POINT./
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 3 (,-] INCHES
0
T
H
E
R
SPECIFICATIONS BY: TITLE:
APPROVED BY: TITLE:
DATE ISSUED:
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 #
/
)
CPHU
EXPIRATION DATE: /- /LI /i
Page 1 of 2
:):=S :CN AND
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e 'Full
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... .. rot E:-'.y o:.. ❑e .'a legally t o:zzec
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or
t o f C',: J • :rsi.. e f o
c_. i�ci, � , numb_ ca pro7cr�y. ( .,. . , ... �._., ., .......
pccifications `.'rom Chnotc-
rtJ.ti?_. \'inir..0 p. ;cifcationa
from
r; Othe. snci fuations, such at, o? crating permit _emu .,.___cr.: ,lord - col.:. a lush toile.^, vetir.:ten'o:ov! .
?3CL=JCA`a ONS 3t': Name of :.:d.vidual providing ac.:cifirr.tions. ::f rlcaig cd c d en_giree_ must aeries:.
,`,.? ?_ICV.:) 3": Cuunty ?..b' c Health Unit (C?` U) personae. reviewing r.rd Cpn -ovm9 permit.
:SSU; D: :Gate perrit is issued by C ?HU.
One year 1r,:m date issued if the system :trn not been ias r ! ec . :?:_. zi:a fo: ayct m repair become voir. 90 says from the date
issued.
PART II - SITE PLAN = • - - - --
*Scale: Each block represents 5 feet and 1 inch = 50 feet. /VC '?(/' f ' •
Notes:
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Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTI PlyRM T
Permit Application Number /7/) -A? ) 0
' /,
i , ,/ 1,
Site Plan submitted by
Not Approved
I
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ALL CHANGES MUST BE APPROVED BY THE COUNTY PUIBLIC HEALTH UNIT
/ , . A ir . -f" (--V'
L A ./ /-> /� r� ' .1 �
In 1 ( Y
qi
Cou Public Unit
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used) Page 2 of 3
(Stock Number. 5744-002-4015-6) 9 _
MIAMI SHORES VILLAGE, FLA.
JOB Di-i-2 2 A-
ADDRESS / 2 1r / 1 e- ,f °` / d'
INSPECTION cf✓ T ' c- !
TIME READY - 7
REMARKS.
. (.) eJ2
N9 6337
INSPECTOR DATE 2 -1 "
MIAMI SHORES VILLAGE, FLA.
JOB 1. j
N° 5944
•
tf
INSPECTION
40-
TIME READY
REMARKS:
INSPECTOR DATE