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285 NE 95 St (8)STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEW GE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT Applicant �rl / Permit umber 872532 223.c. 1 /Jff s ,6/ S -PART 11 - SYSTEM INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL Installer At gr l L)4DE 5C f 7 c. Tank material Co dCgere= Tank level: Yes No Proper tank legend: Yes Other findings. Inspected by C?.i Date Proper gravel size: Yes ✓ No Approved by AN APPROVED INSTALLATIO No Tank Manufacturer Tanks watertight: Yeses_ No Tank size /•//i4 gallons gallons gallons Proper tank outlet device: Yes bo No Manhole or marker.to grade: Yes No _ Dralnfield Trench Absorption Bed El t M WAD gth W Length Width Length 3® feet x /5 feet =9_9_0t feet feet\ feet feet Length feet x feet= ft feet feet /ti/ feet feet Proper No. drainlines: Yes / No /� %I1, feet feet feet feet Proper pipe separation: Yes k . No Total = ft / Total = ft Distribution box level: Yes No ' Systems located as permitted: Yes No d/4 Systems including plumbing stub -outs installed at proper elevation: Yes No " �� Average depth to drainpipe invert from finished.grade: to inches Maximum depth 3 0 Inches Average depth of drainfield gravel: 13 Minimum depth of gravel / " inches Gravel is suitable quality: Yes ✓ No Backfill or fill material as required: (Quality) Yes No (Quantity) Yes No 13/4 a .7'1%11DL4 C /z" ®f Gdfuvei. / lam i ! • �.S PART III - FINAL INSTALLATION APPROVAL Date 7 a(,4/2!) RANTEE PER FORMANCE COUNTY PUBLIC HEALTH UNIT Completed copies of this form will be provided to the applicant, installer and the building department. Form 4016, Jan 86 (Replaces Feb 85 edition which may be used) lumber: 5744 -002- 4016 -4) PE 'e 2 of 2 Abb. BUILDING ❑ MIAMI SHORES VILLAGE, FLORIDA ELECTRICAL ❑ Q 1 Date 49 PLUMBING PERMIT N9 8621 Contractor's ROOFING [� License No. Owner of Building Architect Contractor or Builder .% Legal Description Address of Building Lot CONTRACTOR or BUILDER II Bl Work to be performed under this Permit BY Subdi- vision Sq Ft Value of II Amount of Project $ 11 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. Signed• ": <- (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 regulations 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. AUTHORITY Date 6 Job Address Legal Description Historically Designated: Yes No Owner/Lessee / Tenant 4Z7/4// f /72r f 4 Master Permit # .4 * C i' . 3 ' Owner's Address , �3J1L _ �)' cta a-v; r chlec J Phone 4 (O / - fi Contracting Co. 4 4/I1y Sc W C .... Address Qualifier \ 0 ( u (- (=)( Competency # Ins. Co. Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION (1 4P/X c h APPROVED: Zoning Mechanical Square Ft. (�f wi I a �, . ' 5 4",t rf .,.30) 7 •• i--01( PERMIT APPLICATION FOR MIAMI SHORES VILLAGE 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 OF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR IJv,NDER 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 ELECTRI,C4L 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 do 'compliance with all applicable laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated. 6a Signature of owner and/or Condo President Date Signatur Notary as to Owner and/or Condo President Date Notary as to Contractor or Owner- Builder My Commission Expires: My Commission Expires: FEES: PERMIT RADON r Tax Folio / 6„ Estimated Cost (value) C.C.F. 0 112 NOTARY 5/ 8 �PRYOGB Wm. MARK WOODARD 0 I n <° COMMISSION # CC 625712 c EXPIRES MAR 2, 2001 9 ��� �� BONDED THRU OF F` ATLANTIC BONDING CO., INC. O Electrical BOND 30 za TOTAL DUE 3 3 � --- Structural Engineer May -26 -99 03.10P James D. Keegan ` 01- 1!.U$JJJJ 1J. lU JUJ Mcatgagor WORK DESCRIPTION Square Ft. acT) FEES: PER% APPROVED: Zoning Mechanical ob. -,. 544rrf 7s6 c3)'7,4 fox PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Job Address ..4,?-5 ,Jf . C f, f l Tax Folio Date Legal Description C.JA Historically Desigtetod: Yes No Owner/Lessee / Tenant j�lf �f � � Master Permit $ Oane?s Address / � , / , , Phone Contracting Co. Address Qualifier c l — Q t t n v r x c? o) S it y Sitry State a r 51 0 5 .7Il l Municipal #s,5l./ W o Yi Competency ii Ins_ Co. Archite t/Engin= Address Ebro Co ry Address Address Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN ,,:,Ewt y 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 (,1T' YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOU$ L FNDlIR OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.) Application is hereby made to obtain a permit to do and( and installation as indicated above, and on the attached addendum (if applicable)_ I certify that ate wrgic will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits arc required for E $C m.1c* PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK. OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be ; 'compliance with all applicable laws regulating c. `y • and zoning. Furthermore, L authorize the above named contractor to do the work stated. o " fc , :,t.,�: Notary (4 to Owner or Cando Pir+ident Date My Commission Expires: 305 -661 0195 P.01 I`I1h11•Il Jf"ILJRGJ V 1LLFal7C f HVP Ul/ Ui. (1 / • v 1 /S r - Y >\ Estimated Cost (value) yz Notary as to Coo 1 • tor or Owner-Builder My Commission Expires: . aVe NI Wm. MARK WOODARD r 4 �, COMM'SSION • CC 625712 "T EXPIRES MAR 2, 200 � 60NDEOTN4u OF PP ATVANnC 8ONDING CO., INC. NOTARY BOND TOTAL DUE Electrical Date 3 Structural Engineer - - s I CONSTRUCTION PERMIT FOR: APPLICANT: �p d�.4 A /,'T A 6 LOT: STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC BLOCK: PROPERTY ID #: D R A I N F I E L D FILL REQUIRED: [ ] INCHES 0 T H E R APPROVED BY: DATE ISSUED: ?- r G :.] - Temporary/Experimental [71 Repair [A,1 Abandonment [ p [ ] New System [ m 4 Existing System [Al] Holding Tank er- PROPERTY STREET ADDRESS: "/ - fr ti SUBDIVISION: / (I 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. AGENT: SYSTEM DESIGN AND SPECIFICATIONS T [e� 5 GALLONS ]. AN / GPDSEPTIC 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: [ ] [4 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM, [ ] SQUARE FEET SYSTEM TYPE SYSTEM: [601 STANDARD [ ] FILLED [ ] MOUND CONFIGURATION: [ ] TRENCH [ 1 BED [ ] LOCATION OF BENCHMARK: 1/. 7 `' - P� , Y ( f,,, //7 Y T . 6 A,S" P L c :3 ,--, ;)0 ELEVATION OF PROPOSED SYSTEM SITE [ / c ] [INCHES /FT] [ABOVEBELOW,,] BENCHMARK /REFERENCE POINT BOTTOM OF DRAINFIELD TO BE [ 65 5C. ] rNCHFS /FT] [ ABOVE /BELOW-}$ENCHMARR /REFERENCE POINT SPECIFICATIONS BY: TITLE: 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] EXCAVATION REQUIRED: [ l-2 INCHES DD:LDB © ADITL -DEk TITLE:' _ EXPIRATION DATE: [ CPHU Page 1 of 2 INSTRUCTIONS: PERM1'T NUMBER: Permit tracking number assigned by CPHU. 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. (CPHU may require property appraiser ID 0 or section/township /range /parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 10D-6, FAC. DRAINFIELD: Minimum specifications from Chapter 10D-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 Public Health Unit (CPHU) personnel reviewing and approving permit. DATE ISSUED: Date permit is issued by CPHU. 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.