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450 NE 94 St (5)MIAMI SHORES VILLAGE ' 3UILDING DEPARTMENT ^ �� 305-795-2204 Building Inspection Request Date/ 1 'Y Typelnsp'n �r,'6 n. if S Permit No. ' 05 (49 . Name ce l I`1 Address 45c) I N F c-=‘ 7 � �/; Company c cc 'J ov€ • Phone # Inspection Date Approved Correction Re- Insp'n Fee • ai pt S .1 /71 Roo le- y O A). S7AiY7. Si Az le CC# 96P000219 Affordable Irrigation, Inc. 198 NW 139 Street Miami, FL 33168 A c y 7.2et 7 A ; 70 A 6-7 0 / v,ed 4b, r .,c700 / 7o se4 . e 3 114 13111ILDING PERMIT APPLICATION ,. FOC 2001 Is Building historically Designated YES NO Slate Cei Elude or Registration No. A rchiteel Name (if applicable) S Value of Work For this Permit 'I ype of Work: ElAddilion )Alteration Describe Work: I a s kler j Submittal Fee $ L 5L t.) Notary S Training/Education Fee $ Scamthig S Radon S (*ode Enforcement S 1 obit Fee Now Doe $ (Continued on Opposite side) JL JL L./ JLJL .1 1...4.• t: '61 Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 Zco Permit Fee $ Slate F ,essee Name Phone # Jo Address (where the work is being done) 2- if - 50 Miami Shores Village County Miami-Dade DNew Zoning Structural Plan Review. $ Square Footage Of Work: **************** ***********2?s****************************** Permit No. 91 GC!) Master Permit No. Permit Type (circle): Building Electrical C Plumbing Mechanical Roofing Owner's Name (Fee Simple Tillehoicler).341n 4 kelAca Addiess 1 --150 Sfy Phone # - 1 (ilv , 3n c5-)L -N State F Zip Phone # - 3 0 7-3 Cunt Factor's Company Name ( 'on, t ado! - s Address 8 n ( -1 f3 ( iv Oita I i lief Zip S3 Phone # Zip EJ Repair/Replace ; Li Demolition Ceilificale of Competency No. '?&PLAGD(QI / CCF $ Technology Fee $ Bond $ CO/CC Bonding Company's Name (if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a perrnit ancl that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC 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. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOtllt 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." Notice to .Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted al the job site for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. NOTARY Sign: Prlr' Signature <.' al .- 114- ([j —e_ Signature O er or Agent . 'tractor The foregoing instrument was acknowledged before me this Z3 The foregoing instrument was acknowledged before Inc this day of . QI., . , 20 CS, by , day of -t>°forUQVL/ , 20 05, by M A (zc.,, PjbSi s . who is personally known to me or who has produced vrl+o _is_personally kno sai to me or who has produced As identification and who did take an oath. as identification and who did take an oath. 'mission Expires: � p n n _— s Y:P�� -, Jorge Toledo 'n' • P Ez ires: AUG. 22, 2008 )1:L4 :Expires: 1• F ;�Q OF �` Adana B onded Thrn * * * * * * * * * * * * * * * * * * * * * * * * ** * * * *• * * *;, *• * * * * * * * * * * * * * * * * ** :: *: * * *: *� ***- ** :* :* ::�� * '�� fig 4*a• * *** : : :rr My Commission Expires: APPLICATION APPROVED BY: Chc 05 /13/03 NOTARY PUBLIC: Sign: Print -2 Plans Examiner Engineer Zoning Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 3/3/2005 Applicant: KELLY Owner: MOORE JOB ADDRESS: 450 NE 94 Parcel # 1132060140320 Signed: (INSPECTOR) Plumbing Permit Permit Number: PL2005 -66 MOORE KELLY ST Contractor AFFORDABLE IRRIGATION INC Contractor's Address: 198 NW 139 ST Local Phone: 305 - 681 -6322 Legal Description: MIAMI SHORES SEC 2 PB 10 - 37 LOT 5 & W1/2 OF LOT 4 BLK 51 LOT SIZE Fees: Description Amount FEE2005 -2796 Building Fee $180.00 FEE2005 -2797 CCF $1.20 FEE2005 -2798 Training and Education Fee $0.20 FEE2005 -2799 Technology Fee $4.50 FEE2005 -2800 Scanning Fee $3.00 FEE2005 -2801 Submittal Fee ($50.00) Total Fees: $138.90 Total Fees: $138.90 Total Receipts: $0.00 Permit Status: APPROVED Permit Expiration: 8/22/2005 Construction Value: $2,000.00 Work: LAWN SPRINKLERS Page 1 of 1 MAR 0 4 PAID 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 responisibility for all work done by either myself, my agent, servants or employes. Signed: (Contractor or Builder) BY: MIAMI SHORES VILLAGE, FLORIDA BUILDING ❑ DATE. # ' 19 ELECTRICAL ° PERMIT 6686 PLUMBING 0 N 0 6 6 8 6 Contractor's %'` t ; ( ROOFING License No. Owner of f r i' Building Architect Contractor i or Builder Legal Lot II Description Bl Work to be performed under this Permit__ Address of 1 .1 t Value of 1 Amount of q t ~ Building f ° t t ` Project $ I 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. X Signed. I.fL -r` . _ d \ ,. ja d' INSPECTOR 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 auf`horities of Miami Shores Village. In ae cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee. CONTRACTOR OR BUILDER Subdi- vision BY AUTHORITY • MOT TilligitrIP Owner's Name and MIAMI SHORES VI L AGE PLUMBING INSPECTION DEPAR ENT APPLICATION FOR PLUMBING PERMIT Permit No. Date Application is hereby made for the approval of the detailed statement of the plans and specifications here., subm ted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordif(ance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. State work to be performed and purpose of building (By Floors) ______ New Building � Remodeling —___ -_ Addition Amount of Permit $ STATE OF FLORIDA, D. COUNTY OF DADE. No.__ f// fedi (Signed)- ( Signed )-- _ • ! C Street Registered Architect and /or Engin r ________ — /ra= Employing Plumber's Name // No._ —_ ��_ Z _�: �� Location and Legal Description Lot _______-__ ?i — . _ _ _ — B lock__ v"�_ Svbdivision_P__!Xe ~ Street and Number where work is to be performed —No / £' street 0 - �------------ - - -- -- $otary Public, State of Florida Repairs No. of Stories _ Size Septic Tank Type of Tank_ Capacity Gals. Feet of Drain ------------------------ Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: .... ________Size of Soakage Pit Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and bus com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. Master Plumber. Before me, the u • - signed authoty, notary pine, duly authorized to administer oaths and take acknowledgments, personally appeared to me well lmown who, being by me first duly sworn, upon oath deposes and says that he is the__`/. '`_ _.. of the above described tin, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. (,d7v� NOTARY B'..'?'_ S`*!1` , ra'OR1DA at LARGE MY OtX"iI :SS(1'I C2.27S •S "3 ?/ 1 r i} S0N5 V.,6m3miltsiorE EEpirate:1r NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by impropar notice for inspection, or faulty materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINK6 SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT •NS 0 0'd / - 6.-,' ) .../// TOTAL FIXTURES CONTR. LIST //// i / / _Z— CHECK _�. SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL ?? .•V r, z. Va A i - I - I1 14 -„-, j / __ -__ — _ CONTR. UST / ( / CHECK Owner's Name and MIAMI SHORES VI L AGE PLUMBING INSPECTION DEPAR ENT APPLICATION FOR PLUMBING PERMIT Permit No. Date Application is hereby made for the approval of the detailed statement of the plans and specifications here., subm ted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordif(ance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. State work to be performed and purpose of building (By Floors) ______ New Building � Remodeling —___ -_ Addition Amount of Permit $ STATE OF FLORIDA, D. COUNTY OF DADE. No.__ f// fedi (Signed)- ( Signed )-- _ • ! C Street Registered Architect and /or Engin r ________ — /ra= Employing Plumber's Name // No._ —_ ��_ Z _�: �� Location and Legal Description Lot _______-__ ?i — . _ _ _ — B lock__ v"�_ Svbdivision_P__!Xe ~ Street and Number where work is to be performed —No / £' street 0 - �------------ - - -- -- $otary Public, State of Florida Repairs No. of Stories _ Size Septic Tank Type of Tank_ Capacity Gals. Feet of Drain ------------------------ Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: .... ________Size of Soakage Pit Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and bus com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. Master Plumber. Before me, the u • - signed authoty, notary pine, duly authorized to administer oaths and take acknowledgments, personally appeared to me well lmown who, being by me first duly sworn, upon oath deposes and says that he is the__`/. '`_ _.. of the above described tin, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. (,d7v� NOTARY B'..'?'_ S`*!1` , ra'OR1DA at LARGE MY OtX"iI :SS(1'I C2.27S •S "3 ?/ 1 r i} S0N5 V.,6m3miltsiorE EEpirate:1r NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by impropar notice for inspection, or faulty materials and /or workmanship. r Permit No ' d __ -- Date Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address Jerry, G7 P_e21 - -- _ A----- ..... - N N . E . s treet __ 94th St. Registered Architect and /or Engineer____-_______—___ ________ ____._.-..___.__ .... ____ Employing Plumber's Name SIN GOLD SEPTIC TANK,._IN _ No._-- 4?15Q Location and Legal Description Lot_-_____ ___ _Block_.___ - . Subdivision Street and Number where work is to be performed -No 15.0..-1- FT94th St.. Street State work to be perfor & and purpose of building (By Floors)_ -__ _______.__ New Building 11CC Remodeling ______ ......... _-- -•_- -- Addition_______. .... Repairs MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Size Septic Tank 1000- Feet of Drain Tile. _______S 0' Amount of Permit $_! STATE OF FLORIDA, 1 COUNTY OF DADE. Type of Tank___Sept_ le- __ } Capacity Gals —Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City - Well.______ ...... _ ..... ________ ..... ______Size of Soakage Pit .7 ir t ��� ,a a j�� �7 Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and lias com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by tlie Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. - - - Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aclmowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the_ of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by impro notice for inspection, or faulty materials and /or workmanship. No. of Stories. _ . CLOSETS BATH TUBS S LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBE URINALS U CATCH BASIN FLOOR DRAIN .�. i1NKING FOUNT' NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONT . 1000 50 -- CHECK Permit No ' d __ -- Date Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address Jerry, G7 P_e21 - -- _ A----- ..... - N N . E . s treet __ 94th St. Registered Architect and /or Engineer____-_______—___ ________ ____._.-..___.__ .... ____ Employing Plumber's Name SIN GOLD SEPTIC TANK,._IN _ No._-- 4?15Q Location and Legal Description Lot_-_____ ___ _Block_.___ - . Subdivision Street and Number where work is to be performed -No 15.0..-1- FT94th St.. Street State work to be perfor & and purpose of building (By Floors)_ -__ _______.__ New Building 11CC Remodeling ______ ......... _-- -•_- -- Addition_______. .... Repairs MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Size Septic Tank 1000- Feet of Drain Tile. _______S 0' Amount of Permit $_! STATE OF FLORIDA, 1 COUNTY OF DADE. Type of Tank___Sept_ le- __ } Capacity Gals —Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City - Well.______ ...... _ ..... ________ ..... ______Size of Soakage Pit .7 ir t ��� ,a a j�� �7 Plumbing Inspector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and lias com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are required by tlie Act. The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. - - - Master Plumber. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take aclmowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the_ of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•necessary by impro notice for inspection, or faulty materials and /or workmanship. No. of Stories. _ . ', Date Si FEES: PERMIT APPROVED: Zoning Mechanical PERMIT APPLICATION FOR MIAMI SHORES VILLAGE Job Address 1 1 � ". ; (\; '- ) Tax Folio ■ - 62(.k— Legal Description Historically Designated: Yes No Owner/Lessee / Tenant t (,> j 1 t r Master Permit # Owner's Address 4 Contracting Co. C I A. N, i) rit :(11 1 (' Qualifier State # " ... ‘l Municipal # Square Ft. )(2 t `Notary own er C Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING ELECTRICAL G MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION L IJ k ) I:- 1 - 1.11 -- L I) 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 an d,that all work will- ba me in compliance with all applicable contractor to do the wor stated. laws regulating construction and zoning. Furthermore, I authorize the above -nam 1 A e of owner an.' or Condo •`resident 7 d/or` Condo ssion Expires: ttatt VACA MttMttttWMttMNtttttttttt �`■Y P49 Telmm J. Felder Notary Pubic, ,^.lute' f Florida t i li Commission ice. CC 4 ;:ii 07 OF 0.0 My Comrai:.aica Expires 07/I6f ' > 14O113NOTAAY- Fla I4c Dor.114 CO. > eeeetreeeeeeeemyeeetweiraaetwearaartateA . RADON Date resident Date C.C.F. SS# Address . 1i 1/4 C_ - Phone � l C 76 L- Competency # i,�' ;'� Ins. Co. ] ri'_k 1 Estimated Cost (value) - + - ign Ore of Contractor or ejwner- Builder as to Contra My Commission Ex 1, V NOTARY Building Phone • 1 — K°O 2 - 7 Electrical Plumbing Engineering caner Builder 1 -(039"(-( ;_ )316`s Date 11 Date ) ltttttttttV4Stttt '.ttttttttttSttttttttttKttttt 1t4j � S P U S TerNca J. Felder a, r Not rj Public, Siste . f Florida 'a e C ! 1 ' ) . CC0 1 • " n. My Co:n2.;:a:;a! pircz0't /1v / ' 1.W04-NQTAAY - Fix 1:r., -y ;rvl.v t to- ".., 0((ffeeetee(tai'!.'�Y4Yk( ..:iVitee ;l :e :wow! 4'4 �� TOTAL DUE 3 A - (3 0-4-0 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number PART II - SITE PLAN Scale: Each block represents 5 feet and 1 inch = 50 feet. Notes: Site Plan submitted by: Plan Approved By - 1t t 1 HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used) (Stock Number. 5744-002-4015-6) SIGNATURE 1 .\,- .fix`_ _ 1 1 jr-,, / ,.1 i 1-4 1X - 4 , 'fi (1 j /) }- f i r A r ` jC /(1 ) ( 6 �' '.:,~7t / C ., t . Not Approved ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT TITLE Date % l , County Public Unit Page 2 of 3 CONSTRUCTION PERMITFQR: t' / ] New System [� t -'] Existing System [/[4 ]/Holding Tank pi% Temporary /Experimental V ] Repair i[.4' Abandonment (( ] Other(Specify) AGENT:!' O _ Y'��.G'��! 7 ) / J PROPERTY STREET ADDRESS: , i 3 - ) �,��7✓� S -rik T_ LOT: A' BLOCK: e) SUBDIVISION: / ty /,,, APPLICANT: S—r G t3 PROPERTY ID #:/ / JZ O(� _ d/ (1 - 0 3L 0 [SECTION/TOWNSHIP/RANGE/PARCEL NUMBER] 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. SYSTEM DESIGN AND'SPFrCIFICATIONS 1 T [ £ [GALLONS,/ GPD SEPTIC TAU /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] A [ ] [ / 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: [ ] D 6 Z SQUAB FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [ ] BED 1 ] F LOCATION OF BENCHMARK: j ' F / - ^ +'r C ( ( r c " r. --7,?../ I ELEVATION OF PROPOSED SYSTEM SITE '/ 2 ] TT] ['A OVE /BELOW] BENGRMARI REFERS E BOTTOM OF DRAINFIELD TO BE [ j') c q [INCH9 /FT] [ABOV(IBELOWA) BENCHMA R L D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [...3C, ] INCHES 0 T H E R STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC SPECIFICATIONS BY: APPROVED BY: DATE ISSUED• r TITLE: T I TLF . HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744 - 001 - 4016 -0) INSTALLER/CONTRACTOR PERMIT # 2/ // DATE PAID �`/- / -- 7 FEE PAID $ 5 !AlL7 RECEIPT # 13 3 7 n CPHU EXPIRATION DATE: Y( Page 1 of 2 tracl•15 Ty pry .7 1ype it, if iTz -anocc: fn applicant o:, :30n Ci : LI: :31* charact.... nurolie: (,L1 . 1- o • ea ) AND Minimum Epzcificztionts from CinFte: 10D-S, Minimum specifications from C..22aptor Other specifications, such c; operaling varco p:zviEtr.. :_'11:71.7ATIONS BY: Name of individual providing specificr.tions. If designed by a rest istered :f must be A?: 31 County Public Health Unit 0.7?}I.i.J) personnel reviewing, and approvinz permit. DATE :SSilED: Date permit is issued by CU. 1:72C...):RAT DATE: One year from date issued irthe system 1 not been inlled. il=erf :71 - upr.irs11;:corne vold 90 days fr3m drt:: issued.