712 NE 95 St (6)APPROVED:
Zoning
Mechanical
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 7 ° ZS Job Address —7 / a: ?S � Tax Folio I I - 3Z.OG - 0 14
�1 � r Historically Legal Description WT 1 I ! ( �. �i1 SeC "' Historically Designat Yes No
,
Owner/Lessee / Tenant 1 a-� ►'l -L k • ) ,1 > Master Permit # G' 7,2 2
Owner's Address 112 t, E q E.; Sr f^, ROrteS
Contracting Co. Seri t - G
Co NEC i..oi& tr1
Address 1 ?O ihi\A 2 I #Z M.( I h
Qualifier -,s SS# , Phoney C3 ) (-)Gf-G! ?
State # f\OP U Sl Municipal # ` ' Competency # Ins. Co. NI 'Ft. ti-t k S
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICA PLUMBING. MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION '(
Estimated Cost (value) 3 00 ISO
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.)
Square Ft. 4 O cs
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.
?(, GLIG/A L, Q 7 -&-to
` ., TERESA J. SOLOMON
MY COMMISSION # CC
8 54608
EXPIRES uu; 18
I,800-3-NOnwr Fla Notary Saone & Bontlirp Co.
Signature of owner and/or Con c Pr sident Date
Owner an
My . ' 'ssion Expir
FEES: PERMIT
S .Gib 4.`1 u -
RADON
Date
C.C.F.
Phone)( 1�� 51•- 6 L
elf Contractor of er- Builder
No Ito Contractor or Owner- Builder
Commission Expires:
• :11) NOTARY 5
Electrical
BOND 3/41 O
TOTAL DUE
Date
Date
Structural Engineer
0
T
H
E
R
T
A [
N [
K [
CON TRUCTION PERMIT FOR:
[i,] New System [f Existing System
[ Repair [ Abandonment
AP;PL I CANT :
LOT: BLOCK:
10. !E
PROPERTY ID #:
PROPERTY STREET ADDRESS:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS PER DOSE DOSING TANK CAPACITY
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS &
s
7/ , hi f7:
6
SUBDIVISION:
DH 4016. 10/96 (Replaces HRS -H Form 4016 (page 1) which may b 4-
(Stock Number: 5744- 001- 4016 -0)
/ i TITLE:
A
.ppert
AGENT:
SYSTEM DESIGN AND S,PEC,IFICATIONS
j.
D:.
[GALLONS / GPD] (CEPTIC EROBIC UNIT CAPACITY
] [GALLONS / GPD]
[/ ]Holding Tank [ ,] /Temporary /Experimental
[ 4f410ther(Specify)
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER)
[OR TAX. ID 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. 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.
D ( ,x SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SY TEM
A TYPE SYSTEM: STANDARD [' FILLED
I CONFIGURATION: [ TRENCH [ BED '
F LOCATION OF BENCHMARK: R f a -` a \- ;ra °`" 4) , * ,1) l. f
1 ELEVATION OF PROPOSED SYSTEM SITE [ f,, ] [INCHES /F,SS[ABOVE /BED
E BOTTOM OF DRAINFIELD TO BE [ 1 L. / ] [IN /FT) [ABOVE /Bt
L 41, D FILL REQUIRED: ( - INCHES
PERMIT # r ?5
DATE PAID --T _ 1 _ r t7 0
FEE PAID $ 75 r
RECEIPT #
[ ,J ,
TITLE:
a r'�8' 1
MULTI- CHAMBERED /IN SERIES:[ ]
CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
DOSE •RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
MOUND [ ,y
EXCAVATION REQUIRED: [ 4,.] INCHES
'7. ... N
t..
BENCHMARK /REFERENCE POINT
BENCHMARK /REFERENCE POINT
T , 5 - A - r�
e to ��►
■
CHD
EXPIRATION DATE: 1 *°
vo
Page 1 of
ti
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter I0D -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 Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
4
APPLICANT:
AGENT:
LOT: 0. _,
40
APPLICATION FOR:
[NA New System
(X ] Repair
PROPERTY ID 1:
MAILING ADDRESS: son
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]
PROPERTY SIZE: � ACRES [Sgft /43560]
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
(� ] Existing System ( J] Holding Tank
[N] Abandonment [ N] Other(Specify)
BLOCK: /- a SUBDIVISION:
Olfo
[ ] Garbage Grinders /Disposals
[ ) Ultra -low Volume Flush Toilets
i �2 ;
( %) RESIDENTIAL
No. of
Bedrooms
APPLICANT'S SIGNATURE: V (; C(,
DH 4015, 10196 (Replaces HRS -H Form 4015 (Page 1) which may be used)
(Stock Number: 5744 -001 - 4015 -1)
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel Nod - ZONING:
M( u1!
PERMIT 1
DATE PAID
FEE PAID $
RECEIPT 1
d ,
Temporary /Experimental
TELEPHONE: (?,., .3 (,)6, 3 -.0C
PROPERTY WATER SUPPLY: [ ] PRIVATE
]''Spas/Hot Tubs
] Other (Specify)
] COMMERCIAL
Building i Persons
Area Saft Served
DATE: i
[ 6�
'
Business Activity
For Commercial Only
PUBLIC
[ ]- •f'l'oor /Equipm¢ut Drains
Page 1 of 3
INSTRUCTIONS:
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, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK,
SUBDIVISION:
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot
legal description or deed must be attached.
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
PROPERTY ID #: 27 character number for property. (Health Department may require property appraiser ID# or section /township /range /parcel number.)
PROPERTY SIZE:
Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road
beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
WATER SUPPLY: Check private or public.
PROPERTY ADDRESS: Street address for property. For Tots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 10D-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
BUILDING AREA: Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of structure.
# PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours of operation, or other information required by
Table II, Chapter 1OD -6, FAC.
FIXTURES: Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE: Signature of applicant or agent. Date application on day submitted to Health Department with appropriate fees and attachments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded
easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage
features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and
other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any
public well within 200 feet of lot.
For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential
establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other
features necessary to determine composition and quantity of wastewater.
APPLICANT:
LOT: BLOCK: CI
‘C I]
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
PROPERTY ID #: % 4L p 0
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.
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ]
TOTAL ESTIMATED SEWAGE FLOW: 6,o
AUTHORIZED SEWAGE FLOW: 140
UNOBSTRUCTED AREA AVAILABLE:
SUBDIVISION: mEp,m
BENCHMARK /REFERENCE POINT LOCATION: tr'F - o
ELEVATION OF PROPOSED SYSTEM SITE IS 1,9 [INCHES / [ABOVE /11] BENCHMARK /REF POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE
SURFACE WATER: ?® FT DITCHES /SWALES:
WELL PJBLIC: FT LIMITED USE: N f FT
BUILDING FOUNDATIONS: 9 FT PROPERTY LINES:
PERMIT # 6.)
AGENT: sf„.> "`0c, CoNAN! c [ N
[Section /Township /Range /Parcel No. or Tax ID Number)
YES DO NO NET USABLE AREA AVAILABLE: .'3a ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: fog SQFT
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
r-31') FT NORMALLY WET? [ ] YES x] NO
PRIVATE: NA FT NON- POTABLE: NA FT
15 FT POTABLE WATER LINES: FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [X] NO 10 YEAR FLOODING? [ ] YES [y(] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: -G FT S� /NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture Depth
]eta, c`3j y sA a to
USDA SOIL SERIES: to4$)t,
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: ly e INCHES [ABOVE /
ESTIMATED WET SEASON WATER TABLE ELEVATION:
HIGH WATER TABLE VEGETATION: [ ] YES Ni NO
SITE EVALUATED BY: 22 * D 4.o..6
DH 4015, 10/96 (Replaces HRS -H Form 4015 (Page 31 which may be used)
(Stock Number: 5744- 003 - 4015 -1)
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
%Of. SI I Gal ley SA (D ' tO'n u
1 to
to
to
to
to
to
to
to
USDA SOIL SERIES: L+a y Nkz)
BELOW] EB GRADE. TYPE: [PERCHED / APPARENT]
eft INCHES [ ABOVE / ILO ] EXISTING GRADE.
MOTTLING: [ ] YES ( NO DEPTH: hu` INCHES
e43 DEPTH OF EXCAVATION: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [x] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE: d1 261C0
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential),
Chapter 10D -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.1.
H.1. [ - ] SHOT [ - ] SHOT [ - ] SHOT
Scale: Each block represents 10 feet and 1 inch = 40 feet.
I I
1 I I
I- -
I I
Notes:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT ,
Permit Application Number
Site Plan submitted,by:,
Plan Approved
By
.
DH 4015, 10/96 (Replaces HRS-4-1 Form 4015 which may be used)
(Stock Number: 5744 -002 - 4015
PART II - SITEPLAN
t �
L L
4.
I
I I
cl
Not Approved
r
- --- —
I 1
1
1
1 I I
4
Date "�
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
-
r - , -, T s —
r
I 1
+ C -'
G I
I
I
County Health Department
Page 2 of 4
BUILDING ❑
ELECTRICAL
PLUMBING
ROOFING ❑
Owner of
Building
Architect
Contractor r
or Builder
Legal Lot
Description —
Address of ,,
Building / • '
CONTRACT:5R OR BUILDER
MIAMI SHORES VILLAGE. FLORIDA
DATE 7 ` e
PERMIT 11T° 4 295
-
done by his agents, servants or employees.
Work to be performed under this Permit
Bl
o-
Subdi-
vision
Value of
Project $
Contractor's
License No.
Amount of
Permit $
/11
2
.f+•
195
This permit is granted to the contractor or builder named above to construc the building or to install the equipment or device described in the application
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 knew ge of the ordinances and regulations
pertaining to the work covered hereby whether shown on the plans or drawings cr in the state s or specificatior}tr aiA that he assumes responsibility for work
/
Signed. +.._ BY
INSPECTOR
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinar`�b and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shore A llage. In ac-
cepting this Permil. I assume responsibility for all work done by either, myself, my agent, servant or employee.
BY AUTHORITY e