340 NE 94 St (9)1•
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
10050 N.E. 2nd Avenue • Miami Shores, Florida 33138 • 305-795-2204
Date 3 1 g/ cr2, Job Address 340 N E c't 4 &Y Tax Folio l e 11 32 O 6 — 0 13 - GIG()
Legal Description
Owner /Lessee/Tenet
Owner's Addresses q4-
Contracting Co. fi G Co n 1ec ■ o e
Qualifier
Permit Type (circle one): BUILDING ELECTRICAL
WORK DESCRIPTION:
Square Ft. Lon
Signature of owt.'er an• •r Condo President
N
My
to Owner and/o
ssion Expires
\}<. 4 6
T Qxt so S ri o r,
Plumbing
M Ss e cl P
Historically Designated: Yes No
n
oN P
Date
FEES: PERMIT RADON C.C.F
APPROVED:
Zoning Building
Mechanical
02
SS#
Master Permit #
Phone (3 ,05) 1 S4 - 491
Address sew w 7. Pr- M 1 O vim; 3 3)6 Q
Phone 06°D ° ~6 ro3 - 4
State # L) E-P9 8081'6 Municipal # Competency # Ins. Co. N/1-u 1 I t_i°tzt S
IF THERE IS NO PERMIT PACKAGE ACCESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY,
THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE
BEFORE CALLING FOR ANOTHER INSPECTION.
Estimated Cost (value) cto 2t'GO. 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 ANY 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). 1 certify that
all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understandihat separate permits are required
for all disciplines.
OW.NERS 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.
r
on • resident
(•:
h.•
i. 3NOTARY
.",..:OMO Ii
• 4tS•., • CC 854608
L. .RE. .,
.,;ery Service & Bonding Co.
ita ry-
{
Signature o Co
•
ary as to C ntractor
My Commission Expires
MECHANICAL ROOFING
•
Contractor • r 0 Builder
2/Y
v�� •: 1 • eOFFICIAL 1401 41. a te
ANGELA Pfi LIEC4EN
"\ eePAR SCIO ruC' &En
• 'III' - * CG786697
` erY I007
S OacES
NOTARY .5"-s O a 4 y " BOND D' .
TOTAL DUE
Electrical
Structural Engineer
3/8/ 02.
Date
CONSTRUCTION PERMIT FOR:
[,j] New System [ ] Existing System
[ y..] [] Abandonment
APPLICANT: Gt / 1 1 /t 7 311
7 °
j �
PROPERTY ADDRESS: J 1� e (°
t P! J / 7,,,,...o d .
LOT: � , (o BLOCK: 1 SUBDIVISION: /J /' t. aa. t 7 44 }, e C ' 1 (1)
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
PROPERTY ID #: _ ) / -. 'i '06, - ()l 3 - / 1 G. () [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ " p � ] GALLONS"/ GPD `SEPTI /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES I ]
A [ ] G AtLON ' S "` � / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
N [ •� ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS HOSING TANK CAPACITY [ ]GALLONS ® [ ] DOSES PER 24 BRS # PUMPS [ ]
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
[ L n] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
_
TYPE SYSTEM: I J/ STANARD [ ] FILLED [ ] MOUND 1 1
CONFIGURATION: [ ] TRENCH [ ... BED I l
FILL REQUIRED: [ , j f] INCHES
1 t! 0 1, i V � ,a t-
s �f ti .? i.� (Ai 3 -H It 1 4 I
1 1 I
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: :, J
DE 4016, 12/99
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
1
[0) Holding Tank
[ ] Temporary
LOCATION OF BENCHMARK: ) 1 . /) t)' / I r . t ! a fi
ELEVATION OF PROPOSED SYSTEM SITE [. %� [-INCHES /7T]
BOTTOM OF DRAINFIELD TO BE [ -( ) ,] [INCHES
J��-�t r r �
t t��'li, J •'4 1 .'
TITLE:
(Page 1) (Previous Editions May Be Used)
■
EXCAVATION REQUIRED: [ 3 Q] INCHES
pry,
'L It
"MB
n r, 4111'21
/ I. / 1
pt. 1; Health Department
pt. 2: Applicant
pt. 3: Installer /Contractor
pt. 4: Building Department
PERMIT NO. 0 6 7 tY Z
DATE PAID: 3-7- (i /
FEE PAID: 7,c. (J\)
RECEIPT #: (J
1''•1
[ ]. Innovative IT -.
[ l
e 1 f 1 3 . ✓
[ABOVE /(BELOWL BENCHMARK /REFERENCE POINT
[ABOVE 4BELO BENCHMARK /REFERENCE POINT
EXPIRATION DATE: (
VI c °
Page 1 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT FOR: Check type of permit, if "Other" specify type in blank.
APPLICANT: Property owner's full name.
SYSTEM DESIGN AND
SPECIFICATIONS:
4
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. (CHD may require property appraiser ID # or section /township /range/parcel number)
TANK: Minimum specifications from Chapter 64E-6, FAC.
DRAIINFIELD: Minimum specifications from Chapter 64E-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 Health Department (CHD) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CHD
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.
Scale: Each block represents 5 feet and 1 inch = 50 feet.
?"-
Notes:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT ,
Permit Application Number
° S`f 41 12.
Site Plan submitted by:
0 C) 1
Plan Approved
DH 4015. 1W96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-0(2-4015-6)
tiV1
(p e
'PART II SITE PLAN
Signatur
Not Approved
i •
Ft
ALL CHANGES MUST BE APPROVEOEp4 THE COUNTY HEALTH DEPARTMENT
40 ME c4 8,
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CZKrit I .)(
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Date 6 1 02 -
" • : /
By County Health Department
Page 2 of 3
'
APPLICANT: `dam ✓a
AGENT
PROPERTY ADDRESS:
l
1
1
1
1
1
1
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]
1
1
1
1
STATE OF FLORIDA
DEPARTMENT OF HEALTH;
ONSI'TE SEWAGE TREATMENT • AND DIPQ4AL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
iY
LOT: %% BLOCK: /7,1
r)
(
CHECKED [X) ITEMS ARE NOT IN COMPLIANCE
= ====== =:='S.== ==
TANK INSTALLATION
[01] TANK SIZE [1],`/J `';1 [2]
[02] TANK MATERIAL
[03] OUTLET DEVICE
[04] MULTI- CBAMMBERED [
[05] OUTLET FILTER '
[06] LEGEND
[07] WATERTIGHT
[08] LEVEL ' :� ; p
[09] DEPTH 1 . TO` LID
0
Y
EXPLANATION OF VIOLATIONS / REMARKS:
SUBDIVISION:
WITH STATUTE
DRAINFIELD INSTALLATION
[10] AREA [1], [2] " t�/ SQFT
[11) DISTRIBUTION BOX _ HEADER
[12] NUMBER OF DRAINLINES
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH ' OF COVER Z
[16] ELEVATION (ABOVE /BELOW]_,ABM
[17] SYSTEM LOCATION -' ,,,
[18] DOSING PUMPS t [19] AGGREGATE SIZE
[20] AGGREGATE EZCES VE PINES
[21) AGGREGATE DEPTH
FILL / EXCAVATION MA
[22) FILL AMOUNT
[23] FILL TEXTURE % f
(24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLAC KENT MATERIAL
CONSTRUCTION [APPROVED /DISAPPROVED] : " 4 - ■
. < . U �% ! , 0
f, , a
FINAL SYSTE [ APPROVED /DISAPPROVED] Of, d,- 4. , - d ? ' , � 1 �: o
DE 4016, 10/97 (Pr,vious Editions May Be Used)
ChISTA113i / COMNFC9' 3
PERMIT NO.
DATE PAID:
FEE PAID: .
RECEIPT 1:
PROPERTY ID 1:
f
, suszsmm= = ==--s:
OR RULE AND MUST BE CORRECTED.
OTBAms
t27] SURFACE WATER
FT
FT
[29V PRIVATE WELLS '.. FT
[30] PUBLIC WELLS A. FT
[31] IRRIGATION WELLS FT
[32) POTABLE WATER LINES 4,,• FT
[33] ' BUILDING FOUNDATION FT
[34] PROPERTY LINES FT
[35] OTHER FT
[28] DITCHES
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES .
[39] STABILIZATION
ABANDONMENT
[49] TANK PUMPED /
(50) TANK CRUSHED & F
1� j
..7
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN'
[46] FINAL SITE GRADING
[47] CONTRACTOR
[48] OTHER
CND DATE:
CHD DATE:
Page 2 of 3
PERMIT NUMBER:
APPLICANT:'
AGENT:
MAILING ADDRESS:
LOT, [BLOCK, SUBDIVISION
PROPERTY DID:
COUNTY HEALTH DEPARTMEG■ST CHECKS IX] ITEMS NOT ON COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED V CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK TERIAL (concrete, ffibe
OUTLET FILTER (manufacturer, make, m...181)
LEGEND (manUffeduuser code)
DRAINFIELD AREA *tare feet)
DISTRIBUTION BOX / H ' DER (checCS box)
NURf1BErtOIF DRAINLINES (number installed)
"sVSTER J ELEVATION (in relation to ' M)
DOSING PURIPS (number instalD•:
SET03ACKS (record actua0 set
TANGS CRUSHED AN
lass, etc)
cks in ffil)
FILLED (date)
Permit tracking number assigned by CHD.
S
Pro rdj/ owneu°s 11 ally e t criz uevsentative.
Propprffy owners NH name.
•
p.O. nor street mailing address for applicant or agent.
Lot, Moc ni Sunooivision for Dot or
27 taracter number for property. (TO rly appraiser ID 0 or GIS location)
SETBACKS OTHER (as required)
STABILIZATION (date s,abalized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
EXPLANATION OF VIOLATIONS: Recom l item number,
anata ®n of violation, and requi
AS BUILT INSTALLATION SKETCH
CONSTRUCTION APPROVAL: Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Circle approvt Or d'asapprovel. CHD signature and date of approval.
Final approval shalD not be granted unit the CHD has c onffimr . that building constuctaon and Dot gra are an su. .antial
compliance with plans and specifications submitted with the pemmr t applaution.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OP AGGREGATE
Q¢) SHOT H.O. H.O. H.D.
H.D. • - H SHOT = H SHOT H SH
ELEVATION
0
T
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System
[ X ]Repair [ ]Abandonment
APPLICANT: Perry, William & Dynse
PROPERTY STREET ADDRESS: 340 NE 94 St Miami FL 33138
LOT: 7 BLOCK: 46
PROPERTY ID #: 11- 3206- 013 -6160
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 OR 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
A
N
K
D
R
A
I
N
F
I
E
L
D
STATE OF FLORIDA
DEPARTMENT.OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
tap
750 ]Gallons SEPTIC TANK
0 ]Gallons
O ]GALLONS GREASE INTERCEPTOR CAPACITY
O ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS
[ 150 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ 0 ]SQUARE FEET SYSTEM / -'
TYPE SYSTEM: [pit ] STANDARD [ N ] FILLED ( [ N ]MOUND ['"N ]
CONFIGURATION: [ 1f ]TRENCH [ N ]BED [ .N
LOCATION TO BENCHMARK Top of Bottom Floor, 14.00' NGVD.
ELEVATION OF PROPOSED SYSTEM SITE [ 4.0 ] [ FEET ] [ BELOW]BENCHMARK> REFERENCE
BOTTOM OF DRAINFIELD TO BE [ • 5.5 ] [ FEET ]_ [ BELOW] BENCHMAR /REFERENCE
FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [
OTHER REMARKS:
This permit is not for additions.
*Existing 750 gl septic tank to remain.
*Install 150 sq.ft. of TRENCH DRAINFIELD.
*Invert elevation to be no less than 9.00' NGVD.
*Bottom elevation to be no less than 8.50' NGVD
SPECIFICATIONS BY: Icaza, Carlos
APPROVED BY: Icaza, Carlos
UJ
DATE ISSUED: 8/19/04
OH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 -001- 4016 -0) [needs cons 4016 -11
[ ]Holding Tank [ ] Innovative Other
[ ]Temporary [ NA ]
i
AGENT: SR089722, Zero
SUBDIVISION: Miami Shores
[Section/Township/Range/Parcel No.]
[OR TAX ID NUMBER] •
MULTI- CHAMBERED /IN SERIES: [Y
MULTI- CHAMBERED /IN SERIES: [Y
•
INCHES ;
VIM EMPTI,C'TCalii; COIL 9i� s�)•`$i 1 Pf 9 ; LID
DERECII011 DEVICE 9:3STIf fi.LEO Oil ME ORAL i ME
CENTRAX #: 13 -SG -21978
DATE PAID:
FEE PAID :
RECEIPT .
OSTDSNBR : 04 -2928- -R
TITLE: Engineer I Dade
# PUMPS( 0
EXPIRATION DATE: 11/17/04
POINT
POINT
CHD
Page 1 of 2
PFCEUV CJ
ae e mooao
AGENT:
3
1
1
3
1
1
1
1
PROPERTY ADDRESS:
LOT: BLOCK: V e; SUBDIVISION:
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH
TANK INSTALLATION
[01] TANK SIZE [11/ [2]
[02 ] TANK MATERIAL • - •
[03] OUTLET DEVICE
[04] MULTI CHAMBERED [Y / N.]
[05] OUTLET FILF#1
[06] LEGEND
[07] WATERTIPU ..4 /
[08] LEVEL
[09] DEPTH TO LID
DRAINFIELD INSTALLATION j -,
1 0:01 ARE A [1] s e/ 214[21. r -.
1 ._j 1srBUTIbW BOX
1
1 [151
1 [16 ]
1 [171
] 1181
I [19]
] [20
(21]
[12] NUMBER OF DRAINLINES
[3] DRAINLINE SEPARATION
[14] DRAINLINE sLOPE
DEPTH OF COVER
FILL
[22]
[231
(24]
[251
[26]
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONS 1TE SEWAGE TRRATMENT AND
CONSTRUCTION INSPECTION AND
ELEVATION [ABowtpso)
SYSTEM LOCATION
DOSING PUMPS
AGGREGATE SIZEli
AGGREGATE EXCSSSIVE FINES
AGGREGATE DEPTH
/ EXCAVATION MATERIAL
FILL AMOUNT
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEKENT MATVRTAL
EXPLANATION OF / REMARKS: —!
[ 1
CONSTRUCTION --[..ApPROVtD/DISAPPROVED)
---
FINAL SYSTEM tAPPROVED/DISAPPROVED]: .- .,li/av
‘ , r
DK 4.016, 10/97 (prAvious Editions may Be used)
'4'
t
PERMA • NO . - •
5e
DATE PAID:
DI SP OSAL SYSTEM FEE PAID:
FINAL APPROVAL RECEIPT #:
• .• PROpE:RT.X.,:;;IDi
STATUTE OR RULE AND MUST BE CORRECTED.
[ 61 , ppAIWIELD COVER
FILLZD / MOUND YeTEM
t 1 [381 SLOPES
[ 3 (391 STABILIZATION
1 t
SETBACKS
[271 SURFACE WATER
[28] DITCHES FT
[29] PRIVATE WELLS f
[30] PUBLIC WELLS i FT
[311 IRRIGATION WELLS — . FT
(32] POTABLE WATER LINES FT
[33] BUILDING FOUNDATION FT
(34] PROPERTY LTNRS FT
[353 OTHER VT
ADDITIONAL INFORMATION
[401 UNOBSTRUCTED AREA
[411 STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44) BUILDING AREA
[45] LOCATION CONFORMS WITH SIZE PLAN
[46] FINAL SIZE GRADING
[47] CONTRACTOR )1"")
[48] OTHER
ABANDONMENT
] (491 TANK PUMPED / /
] [50] TANK CRUSHED & FILLED _ /
CHD DATE:
-,---
CHD toTE
(!., .:'? k • • 7 ; ,..Z1,"IC
I $ 1... q 1 i t.:6••■ • ....• - - kage 2 of 3
PT 1: Appliegft
PT 2: Instiller/Contractor
PT 3; I:Wilding Department
PT 4: Health Department