230 NE 94 St (9)z , PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address NZ.- 9 1 /71-137 Tax Folio /1 3.104
Legal Description L OIS 3 4 /A) ixtre.1.7 Historically Designated: Yes No
/4 - 44L7v • afr RSA? o,C o/ /*i9/ )/A
Owner/Lessee / Tenant ti/Lt... / RD? LT <TM /7N Master Permit # 'H
Owner's Address r? 3 NL' 9 %771 Phone - 9j-Q-41
Contracting Co. L LOYD - A}O72TN D 527 7lG Address /1141/• ///
Qualifier '1 IDS Ba. m)o z SS# / /Phone %J 76-74,
State # Municipal # 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 — 7/1J 'LG b SFr P /AJ/3'r2
Square Ft. Z Estimated Cost (value) /G'.
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.
5/44A.'"at
f owner and/o • o President
Notary as to Own
My Commission Expires:
76 ,:i o n LESTER E. CROCKETT
9\ My Comm Exp. 5/20/2001
rNOTAR
■Ln PUBLIC n Bonded By Service Ins
No. CC649326
1 1 Personally own 1 1 Other I
FEES: PERMIT L) RADON
i nt ' Date
APPROVED:
Zoning Building
Mechanical Plumbing
4 f
Date
t/
C.C.F.
is•
it : i ntractor • 1-01 e :
04i
Notary as to 71 trac • •- - I T 1 •
My Commissio Expires:
LESTER E. CROCKETT
My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
f 1 Personally Known f 1 Other I D
Date
er Date
NOTARY BOND
Electrical
TOTAL DUE
Engineering
O
T
H
E
R
CONSTRUCTION PERMIT FOR:
(!J] New System [/J Existing System
()A] Repair (h-� Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT: ( a > BLOCK:
7
i e - ' - j - S I . I
PROPERTY ID #: '•( _ :;320t,,- 0 13- 3G,30
D [ 3 U(z] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R ( - ] SQUARE FEET SYSTEM
A TYPE SYSTEM:
I CONFIGURATION:
N
F
I
E
L
D FILL REQUIRED: 01)u ] INCHES
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: t i) /5
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS &
Z.
OH 4018, 10196 (Replaces HRS -H Form 4016 (paps 1) which may be used)
(Stock Number: 5744. 001. 4016-0)
Chapter 1OD -6,
PERMIT $ ° 1 ! R -6)51 7
DATE PAID y - . <o -`;; I FEE PAID -$ 7 7'.O 0
RECEIPT if 7..'=;/00
FAC.
((` Holding Tank (N] Temporary/Experimental
( tJ] Other(Specify)
AGENT: h 1,3 ld y-(4- 1-, _ ve i L
23 Alt /4, 'L. 33( C Z
SUBDIVISION: /l/ , 4,4 r
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. DEPARTMENT OF HEALTH 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.
�o es
( SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX • NUMBER ]: ; ,,. r , .<,. .. •
= == == = == ==
== ______________
SYSTEM DESIGN AND SPECIFICATIONS
1 `i// ;Tto9
T- ( 1001
GALLONS)/ GPD] OPTIC 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: ( )
[-/ STANDARD ( ] FILLED [ ] MOUND
[ J TRENCH . ( lam BED ( ]
/, 0J F. 1' �. /pa C e - 1 /r;c -At < 1�, <4-- ‘41-1
LOCATION OF BENCHMARK: _
ELEVATION OF PROPOSED SYSTEM SITE ( /2.) 1] (INCH> FT) (ABOVEA ELO� BENCHMARK /REFERENCE - POINT,
BOTTOM OF DRAINFIELD TO BE [ 9. 2 . u() ] (INCBESJFT] (ABOVELBELOW] )$ENCHMARK POINT
TITLE:
(
EXCAVATION REQUIRED: ( 3 0 3 INCHES
INSTALL 12' OF LOAMY COARSE SANL.
UNDtH ISO 1 1 UM 01- ut iftiLJrfL�C�
:;U1.3RrMI
APPU CI4 1T
TITLES act . T . -Lie t CHD
EXPIRATION DATE: -7/ (1 / ,
Page 1 of 2
Notes* s
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II SITE PLAN
• ' •
HRS-H Form 4015. Feb 85 (Obsdetes previous editions which may not be used)
(Stock Number 5744-002-4015-6)
, „ . - •1••
,
• 7',„# '
f
. t• e e 1/4/ • p
Site Plan Submitted by
SIGNATURE TITLE
Plan Approved 7> Not Approved Date
By County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Page 2 of 3