790 NE 95 StSTATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Applicant H,4/%1 00A/1;0 0A1i 6. ^i /' Permit Number 56 a_734
%-eMra s3 , 79 a .v, c - • i 3 - S i ,6 / 32
PART II - SYSTEM INSTALLATION INSPECTION AND FINAL INSTALLATION APPROVAL -
Installer i1; 4i1s ! 'O
/ �ee -.2. .j� 1/1^3X- Tank Manufacturer
Proper tank legend: Yes No Tank material Tank level: Yes No
Tanks watertight: Yes No Tank size• gallons gallons gallons
Proper tank outlet device: Yes No Manhole or marker to grade: Yes No
Drainfield Trench Absorption Bed
Length Width Length Width Length L) feet x / 0 feet = ft
feet feet feet feet Length feet x feet= — ft
feet feet feet feet Proper No. drainlines: Yes V No
feet feet feet feet Proper pipe separation: Yes No
Total = ft Total = ft Distribution box level: Yes No
Systems located as permitted: Yes I
Systems including plumbing stub -outs installed at proper elevation: Yes No
Average depth to drainpipe invert from finished grade / 7 inches Maximum depth Inches
Average depth of drainfield gravel: /.3 inches Minimum depth of gravel inches
Proper gravel size: Yes 1- No Gravel is suitable quality: Yes Lr No
Backfill or fill material as required: (Quality) Yes ✓ No (Quantity) Yes ' No
Other findings: rEAwi f� -e4cst l o c_.< /' /4,,,... 4 c r'd,„' ,
Inspected by
Date
Approved by
6 � � . J4
PART III 'NAL INSTALLATION APPROVAL-
.-
AN APPROVED IN ALLATI N DOES NOT GUARANTEE PERFORMANCE
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
HRS —H Form 4016, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744- 002 - 4016-0)
Date 8/i/8 .
COUNTY PUBLIC HEALTH UNIT
Page 2 of 2
BUILDING ❑
Owner of
Building
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot
CONTRACTOR OR BUILDER
MIAMI SHORES VILLAGE. FLORIDA
ELECTRICAL ❑ DATP 195
PLUMBING ❑ PERMIT N? 7991 Contractor's
License No
ROOFING ❑
❑ Work to be performed under this Permit
Bl.
Subdi-
vision
Sq. Ft
Value of
Project $
Amt. of
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 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 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 responsibility for work
done by his agents, servants or employees.
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 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 responsibility for all work done by either, myself, my agent, servant or employee.
BY AUTHORITY '
t7