135 NE 94 St (19)STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ ]New System [ X ]Existing System [
[ ]Repair [ ]Abandonment
APPLICANT: Gordon, Cordinel AGENT: OWNER,
PROPERTY STREET ADDRESS: 135 NE 94 St Miami Shores FL 33138
LOT: 19 BLOCK: 21 SUBDIVISION: Miami Shores
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11- 3206 - 013 -2881 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ]Gallons SEPTIC TANK MULTI- CHAMBERED /IN SERIES: [Y ]
A [ 0 ]Gallons MULTI- CHAMBERED /IN SERIES: [Y ]
N [ 0 ] GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 JDOSES PER 24 HRS # PUMPS[ 0 ]
D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ N ]STANDARD [ N ]FILLED
I CONFIGURATION: [ N ]TRENCH [ N ]BED
N
F LOCATION TO BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ 0.0 ] [ FEE
E BOTTOM OF DRAINFIELD TO BE [ 0.0 ] [ FEE
L
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIR
OTHER REMARKS:
[CP] Scope of work: Enclose existing terrace to create new family room [200 sq. ft.]. Will
not be increase in sewage flow, change in characteristics or expected disruption to the
existing septic system or invalidating unobstructed reserve area reduction. No action
shall be taken.
SPECIFICATIONS BY: RAM,
APPROVED BY: Test II,
DATE ISSUED: 3/3/05
TITLE:
DH 4016, 03/97 (Obsoletes previous e•itions which may not be used)
(Stock Number: 5744- 001 - 4016 -0) [ostds_cons_4016 - 11
ED: [ 0.0 ] INCHES
CENTRAX #: 13 -SG -24088
DATE PAID:
FEE PAID : $
RECEIPT
OSTDSNBR : 05 -0675- -E
]Holding Tank [ ] Innovative Other
]Temporary [ NA ]
[ N ]MOUND [ N ]
[ N ]
T ] [ BELOW ] BENCHMARK/REFERENCE POINT
T ] [ ]BENCHMARK /REFERENCE POINT
TITLE: EH Specialist I Dade CHD
EXPIRATION DATE:
Page 1 of 2
APPLICATION FOR:
[ ] New System
[ ] Repair
APPLICANT :, t` Vt -
MAILING ADDRESS:
I s —
) . TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
PROPERTY INFORMATION
LOT: I BLOCK: ? SUBDIVISION: �. 1 = / ' =
PROPERTY ID #:
PROPERY SIZE: ,`'ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [ ] <= 2000GPD [ ] >2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y /1i)] DISTANCE TO SEWER: FT
PROPERTY ADDRESS:
DIRECTIONS TO PROPERTY: f ), fig•
`!
BUILDING INFORMATION
Unit Type of No. of Building Commercial /Institutional System Design
No Establishment Bedrooms Area Sqft Table 1, Chapter 64E -6, FAC
1
2
3
4
( ]
{ fl
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
[ ]
[ ]
Floor /Equipment Drains
Existing System
Abandonment
( ry
..,
br ;9 kJ •-,
[ v] RESIDENTIAL [ ] CORCIAL
[
SIGNATURE: ( C• # '.
1I ➢N'1: v
[
] Other (Specify)
:?r"C- f:ll C3 :iii•.
DH 4015, 10/97 — Page 1 (Previous editiori may be used)
Stock Number: 5744 - 001 - 4015 -1
- -PERMIT 16: )t,
` -s... DATE PAID:
FEE PAID:
RECEIPT 1:
] Holding Tank [ ] Innovative
[ ] Temporary F. ]
ZONING: I/M OR EQUIVALENT: [ Y / N ]
q t. 1; ' =, i L..
DATE:
PLATTED:
r
TELEPHONE: ; ' ' -; •
Page 1 of 3
Scale: Each block represents 5 feet and 1 inch = 50 feet.
A
Notes:
• "
Site Plan submitted by:
: c
DH 4015. 10/98 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-8)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGEDISPOSALVSTEM CONSTRUCTION PERMIT
Permit Application Number
4
PART II - SITE PLAN
•
• .■
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Signature Title
Plan Approved Not Approved Date
By County Health Department
Page .2 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes:
Site Plan submitted by:
DH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744 - 0024015 -6)
PART II - SITE PLAN
Signature Title
Plan Approved Not Approved Date
By .. County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 3
APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM'` c.
SITE EVALUATION AND SYSTEM SPECIFICATIONS
/D G �f /
C. U ✓► ��Q+ � ) AGENT: (� S �/-
�l7XS 66IL
LOT: / p BLOC 2/ SUBDIVISION: /4 4
PROPERTY ID is
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: 3a4
AUTHORIZED SEWAGE FLOW: 59
UNOBSTRUCTED AREA AVAILABLE:
ELEVATION OF PROPOSED SYSTEM SITE IS 3• [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THk MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: /c&) FT DITCHES /SWALES: f FT NORMALLY WET? [ ] YES [A NO
WELLS: PUBLIC: .4 FT LIMITED USE: ,(p FT PRIVATE: ;ck FT NON- POTABLE: FT
BUILDING FOUNDATIONS: ) FT PROPERTY LINES: /t FT POTABLE WATER LINES: Z; FT
BENCHMARK /REFERENCE POINT LOCATION:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [.4 NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell / /Color Texture
.S1
lfvpa,- -°
USDA SOIL SERIES: 6,42,6
Depth
to
top
to
to
to
1 to
1 to l
to
to
!.A Ks':
OBSERVED WATER TABLE: f A INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION,: INCHES [ ABOVE BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [y] " NO MOTTLING: [ ] YES El NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: lik4LEEt DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [/1 BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY:
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used)
(Stock Number: 5744- 003 - 4015 -1)
PERMIT #
[ Section /Township /Range /Parcel No. or Tax ID Number]
YES [ ] NO NET USABLE AREA AVAILABLE: o ,Z 3 C ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
10 YEAR FLOODING? [ ] YES [/) NO
SITE ELEVATION: 40 FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
®
1 I. -9 / ) C -' to i,/ ''
to
to
USDA SOIL SERIES: ,Q &e,Q,f
to
to -
7 — to
/ to
1
INCHES
DATE: ,,
Page 3 of 3
/, •
Vinive of Miami Shores
JOB
ADDRESS
INSPECTION
/
TIME READY
REMARKS ()
N? 4028
, „ 7
(
/
INSPECTOR DATE =`;"
0
Date 1/02/96
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 135 NE 94 STREET
Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant MAJORES Master Permit #
Owner's Address 135 NE 94 STREET Phone 795 -2207
ContractingCo. NORTH DADE SEPTIC TANK
Qualifier DENNIS NEVTT.T.F. SS# Phone 754 -3375
State# 025836 -8 Municipal# Competency# 12842 Ins. CoTRAVELERS /ESIF
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION INSTALL DRAINFIELD
Square Ft. 300 Estimated Cost (value) $ 1000.00
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'
law
gul
APPROVED:
Zoning
Mechanical
FIDAVIT: I certi
construction
G1 — 1/02/96
S gnature of owne and/or Con resident Date
t all the foregoing information is accurate and that all work will be done i compliance with all applicable
zo g. Furthermore, I authorize the above- narr3ed3sontractor to do the work stated.
Notary : Owner and/or
My Commission Expires:
1±±,S: PERMIT 0 ` j
do 'resi lent Date
* °° ; 1e esn J. Feld:;
Nc'Irry :'oblic S1,itc of Flo'
• if Commission No. CC 429307
oi ne . My Commission Expitos 07/16/99
> 3NOYARY • n,. Notary Service & Sontag Co.
ate teeetteeetetatoate atteeeeeeeeeeeteetere
1- &00.
Not
RADON C.C.F. • SD
Address 800 NW 111 STREET, MTAMT 33168
of Corlt4ctor or Owner - Builder
Contractor or
My Commission Expires
NOTARY
Electrical
3 R 9/
1/02/96
Date
96
er -B lder Date
.v
1; J. r. eci;
; " !VG «uy T�tiii i' 0114.rirla
. Commiri; r Iao. CC 4i;;!::i{7
` Q n r es aoMy Commission Exr it es 07/16/99 t
j C)
TOTAL DUE . •
Engineering
•
APPLICANT:
/rA
PROPERTY STREET ADDRESS:
PROPERTY ID #:
[GALLONS
A [ ] [GALLONS
N [ ] GALLONS
K [ ] GALLONS
0
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
CONSTRUCTION PERMIT FOR:
[ ] New System [`,.] Existing System
['�] Repair [`] Abandonment
BLOCK: SUBDIVISION:
ipw
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D- 6,JFAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMIT.°
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. SU'
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
SYSTEM DESIGN AND SPECIF CATIONS
/ GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
/ GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
D [ y SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: ( ] INCHES
SYSTEM
[ ] STANDARD [ ] FILLED [ ] MOUND [ ]
[ ] TRENCH [ ] BED [ ]
; Holding Tank
AGENT:
[OR TAX ID NUMBER]
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0)
EXCAVATION REQUIRED: [ ] INCHES
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
Temporary /Experimental
Other(Specify)
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXPIRATION DATE:
CPHU
Page 1 of 2
TN .2J: "::DNS:
'fsr $' IZr3s L: ?. :rnit :racking number assigned by CP .U.
A.?? Chec!: type of permit, if "Other° specify type in blank.
Property owner's full name.
.E.P. ?:Citts.: Telephone number for applicant or agent.
?ropar'y owner's legally authorized representative.
ADDRESS: ?.C. box or street mailing address for applicant or cgent.
SU3DIV 7.SION or
27 character id number for property. (CPHU may requ prcper:y r.ppraiser ID 11 or section /township /range /pi:reel nurnecr)
SY' .. '.'.;.:5I.CN AND
f ' Minimum specifications from Chapter 10 D -6, YAC.
Minimum specifications from Chapter 10D -6, rlAC.
:i'::.. R: Other specifications, such as operating permit requirements, tow - volume' flush toilets, varicnco provisos.
-y.'' f,7 7- ICNS BY: Name of individual providing specifications. • If deeigred by r: registered engineer muss be sealed.
-: ?:.OWED 3Y: County Public Health Unit (CPHU) personnel reviewing cnd cpproving permit.
D,',TE •■SSUED: Date permit is issued by CPHU.
E.', ?'_RATION DATE: One year from date issued if the system has not been installed. ?ermits for system repairs become void 90 days from the date
issued.
Scale:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number "''`j °>
PART II - SITE PLAN
Each block represents 5 feet and 1 inch = 50 feet.
• • ■••••M IMMM ■_ ■■ ••••••■
■ ■iii ■i_i_■■Iiii rte■_® •••••••
■ ii ■litG ■_i ■� i• ■_■■ •■ •■ ■ •■
■ •111■+' ■i-. ■_ ■ ■. MUM _■_®■ •••••••
• C i �i�•C �EMI.11i..1l.
1 I I 1i11 _■_„■ •••••••
• ._.■_■■� ■_■
■ ■ice_ ■ ■_■■r .. >� L
1 IUA ._ o-. +yd ` r: iC c
f
1�■1 1111111 ® ■■■ ■ ■ ■■
iI It ill 1111111
■ ._..�.■ �..� . _ ". ■ ■ ■■ ■ ■.
11 U l� 161 /ta , E _U1 ii•i.■■
1
1 _ _ i11!1________ �� ■111111111
it ■�S1 ■E■�. i _ ■■ ■ ■ ■ ■ ■ ■■
1 1 p III 1111111
1 1 1 1 111 IHIIII
11 1 llIlI IlilIlilhlIl
11 1 l - Lill /111111111
1 1111 - ulilplIlIll
............
.M111=111 ■ ■MMIIIIIM_ ■_ s_.■ _ =f::.. ■ ■■■■■
Notes: .
Site Plan submitted by:
Plan Approved
SIGNATURE
By
r
Not Approved Date
County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015 -6)
TITLE
Page 2 of 3
4
•••
4-
.... • • • ^^
•
APPLICATION FOR:
] New System ;[ ] Existing System
( ] Repair [ ] Abandonment
APPLICANT:
AGENT:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
1
2
3
4
MAILING ADDRESS:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIV* Z;
==c- == ,fit = = =._ - = ==
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEuj ---
BLOCK:
DIRECTIONS TO PROPERTY:
r�s
PROPERTY STREET ADDRESS:
BUILDING INFORMATION [•. ] RESIDENTIAL
Unit Type of No. of
No Establishment Bedrooms
] Garbage Grinders /Di posais
] Ultra -low Volume Fl Toilets
//
APPLICANT'S SIGNATURE:
ACRES [Sqft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
(.1
SUBDIVISION:
] Holding Tank
'J Other(Specify)
[ J COMMERCIAL
PERMIT #
DATE PAID
FEE PAID $
RECEIPT 1
TELEPHONE:
] Temporary /Experimental
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
Building # Persons Business Activity
Area Sqft Served
For Commercial Only
] Spas /Hot Tubs ;,{ ] Floor /Equipment Drains
{ ] Other (Specify)
DATE:
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) Page 1 of 3
(Stock Number: 5744- 001 - 4015 -1)
INSTRUCTIONS:
APP.;.'_CATION FOR: Check type of permit, if "Other' specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for npplicant or agent.
AGENT: Property owner's legally authorized reprosentetive.
MAILING ADDRESS: P.O. box or street, city, state end zip cceie mail n eddresa for applicant ow agent.
LOT, BLOCK,
SUBDIVISION:
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat book° (month /day /year) or date lot originally recored. Dividing on approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
Lot, bloc's, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, n copy of the lot
legal description or deed must be attached.
27 character number for property. (CP} U may require property appraises ID 0 or section/township /range /parcel number.
Net usable arec of property in ecres (square footage divided by 43,560 equare feet) exchiaivc of al paved creao end prepared road
beds within public rights -of wry or eacements and exclusive of sir amo, lakes, normally wet drainage ditehea, r crrhea, or other
such bodies of water. Contiguous unpaved and noncompected road rights - of-way and ceeeraents wil% no aubeu: face obstructions
may be included in calculating lot area.
WATgR SUPPLY: Check private or public.
PRO: ERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
D! ECTIONS: Provide detailed instructions to lot or attach au area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT:
NO. BEDROOMS:
BUILDING AREA:
/) PERSONS:
BUSINESS ACTIVITY:
FIY.TUt2BS:
SIGNA T :JIBE:
AT FAC 'J NTS:
List type of establishment from Table u3, Chapter 19D-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodetions for
occupants.
Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage tilled, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
Number of persons residing, using, or working in establishment. !For residential ea;.ablit meat, 2 aercona pee bedroom a.
assumed.
For commercial application:, only. List number of employees, chifts, and houro of operation, er other information required by
Table 11, Chapter 10D -6, FAC.
Mark each listed fixture with number installed or "NA" if net applicable.
Signature of applicant or agent. Date application one dry :submitted to the CPHU with appropriate f ea and attachments.
For residences, a floor plan (residences) showing number of bcdrooma and building emu of each unit. T ror r_onreaidcntial
establishments, a floor plan showing the square footage of the establishment, ail plumbing drains and fix,urc types, and other
features necessary to determine composition and quantity of wastewater.
A site plan drawn to scale, showing Boundaries with dimensions, location° of residences or buildings, aw!':tming pools, recorded
easements, onsite sewage disposal system components and loch. ion, elope of property, any existing or proposed well°, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite eewngs diapocal uyctsnta, surface waters, and
other pertinent facilities or features on adjacent property, if the features ere with 75 feet of the applicant lot. Location of any
public well within 209 feet of Lt.