460 NE 95 St (3)Date /61; Job Address
Legal Description
Owner / Lessee / Tenant 2 C--t% tw6 Master Permit #
Owner's Address n Phone
Contracting Co. G .i4/ //9 Address
Qualifier SS#
State # Municipal #
WORK DESCRIPTION
Square Ft. Estimated Cost(value)
Signature of
Date:
Notary as to Owner and /or Condo President
My C •
` p-AY P( OFFICIAL NOTARY SEAL
O e ei SANDRA M MONTIEL
� N y * runup NUMBER
** * 4 , s < CC411211 * 1 *
-7 4 p MY COMMISSION EXP.
FEES : I Ethittf4 AUG. 17, t, i 1
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
cyraw
and /or do President
r
6 � /Vt.; q
7 &let
c 7?.
/0 i
Zoning Buildin
Mechanical Plumbin
Tax Folio
Phone
Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL LUMBING MECHANICAL ROOFING PAVING PENCE SIGN
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.
Signature of Contrac or or Owner- Builder
Date:
No
My
3 C
J C ,j Ic-77
a =.s to Contractor or Owner - Builder
16 �R£iARY SEAL
* SANDRA M MONTIEL
COMMISSION NUMBER
Q * CC40 }261 * * **
(ate MY COMMISSION .EXP.
OF F kLIG 1 19814
NOTARY """ °4UE 31
*
C.C.F. 1
Fire Other
Electrical
�Qtf�
+C Engineering
CONSTRUCTION PERMIT FOR:
ev, ] New System Existing System
] Repair [] Abandonment
APPLICANT: ' q
f ri
PROPERTY STREET ADDRESS:
LOT:
SYSTEM DESIGN AND $PECI-FICATIONS
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
(,_
[
TYPE
CONFIGURATION:
LOCATION OF BENCHMARK
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
FILL REQUIRED: [ ] INCHES
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 1OD -6, FAC
t
[ ] TRENCH
z. r <fita
}'Holding Tank
VV] Other(Specify)
r , AGENT:
BLOCK: SUBDIVISION:
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)'*
(Stock Number: 5744 - 001 - 4016-0) ', tKL%w'
PIPI.F. CAN T
[
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
^'}'Temporary/Experimental
'r
PROPERTY ID #: [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
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. 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.
L [GALLONS -'/ GPD], SEPTIC 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: [ ]
SQUARE FEET PRIMARY DRAINFIELD SYSTEM
] 'QUARE -J FEET SYSTEM
SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [
BED
]
[
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ <..._ ] INCHES
EXPIRATION DATE:
CPHU
Page 1 of 2
e/
APPLICANT: /
LOT:
PROPERTY ID #:
SITE EVALUATED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: `/-
/7
d
BENCHMARK /REFERENCE POINT LOCATION:
PROPERTY SIZE CONFORMS TO SITE PLAN: [
TOTAL ESTIMATED SEWAGE FLOW: ''
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
SOIL PROFILE INFORMATION SITE 1
.4
SUBDIVISION:
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.
] YES [ ] NO NET USABLE AREA AVAILABLE :'e ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: / SQFT
Munsell # /Color
USDA SOIL SERIES:
_Texture
Depth
to
to
to
to
to
to
to
to
to
[Section /Township /Range /Parcel No. or Tax ID Number]
ELEVATION OF PROPOSED SYSTEM SITE IS . `Is; [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED.FROM THE PROPOSED SYSTEM TO TH�,F FOLLOWING FEATURES*
SURFACE WATER: ^ �r . FT . ('' ,, ' - H CHES /! /ALE '/ Z P FT _ IO L,Y9 -WiT(" [ 1 _YES. 1 NO
WELLS: PUBLIC: •f,i. 1 FT LIMITED USE: ' •.` FT PRIVATE: ��= `�;`�' FT NON - POTABLE: FT
BUILDING FOUNDATIONS: , FT PROPERTY LINES: r FT POTABLE WATER LINES: FT
1
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES ( ] NO 10 YEAR F�1. 1 r NG? [ ] YES ( NO
10 YEAR FLOOD ELEVATION FOR SITE: r" FT MSL /NGVD SITE ELEVATION: .° FT MSL /NGVD
OBSERVED WATER TABLE: ,?//,' INCHES [ABOVE / BELOW) EXISTING,GRADE „-,'TYPES [Pz„RCHED d6APPOp
ESTIMATED WET SEASON WATER TABLE ELEVATION: 17. INCHES [ ABOVE /^ BELOW ] EXISTING GRA'6E.
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ >'] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not ba.us
(Stock Number: 5744- 003 - 4015 -1) 1) t
AGENT:
PERMIT #
SOIL PROFILE INFORMATION SITE 2
DATE:
Munsell # /Color Texture Depth
]
INCHES
Page 3 of 3
APPLICATION FOR:
(I New System [e Existing System
IV) Repair [AA
APPLICANT: • -
AGENT:
MAILING ADDRESS: / �
LOT: �>
PROPERTY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
•
Y
4 �
APPLICANT'S SIGNATURE:
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
Abandonment ] Other(Specify)
BLOCK:
Affi-
'>
1
}
"] Holding Tank [4d) Temporary /Experimental
7
TELEPHONE:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
SUBDIVISION: 1 DATE OF ,
/° SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ '1 PUBLIC
[ r ] Q RESIDENTIAL
No. of
Bedrooms
[ ] Garbage Grinders /Disposals [ ] Spas /Hot Tubs
Building
Area Sgft
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4015-1)
[
] COMMERCIAL
# Persons
Served
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
Business Activity
For Commercial Only
[ ] Floor /Equipment Drains
[ ) Ultra -low Volume Flush Toilets [ ] Other (Specify)
DATE:
i
Page 1 of 3
Site Plan Submitted by
Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II SITE PLAN
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By
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4015-6)
SIGNATURE
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Notes
TITLE
Not Approved Date
County Public Unit
Page 2 of 3
BUILDING
ELECTRICAL
PLUMBING
WORK
DOE BY:
• • ITTCirESTRI
The Following is ready for inspection:-
Inspector's Report:
ADD: Y 6
: WILL BE READY