541 NE 94 St (4)STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
Pernh NumbePJfC f
PART 11 - SYSTEM INSTAL TION INSPECTION AND FINA INST LATION'APPROVAL---------------
Installer G ; -t Tank Manuf- cturer J1..
Proper tank legend: Yes/ M No Tank material P / " � . k level: Yes
✓ /
Tanks watertight: Yes 4 No Tanksize:Jc gallo
Proper tank outlet device: Yes ' No
Drainfield Trench
Applicant
Other findings
Inspected by:
Length Width
feet feet
feet feet
feet feet
Total = ft
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744002 - 4016 -4)
PART III - FIN L STALLATION APPROVAL
Date,? ? 74 pproved by:
AN APPROVED INSTALLATION DOES NOT GUARANTEE PERFORMANCE
gallons gallons
Manhole or marker to grade: Yes /VI No
Absorption Bed
Length width Length
le -6
feet x feet= ft
feet feet Length feet x feet = ft
feet feet Proper No. drainlines: Yes No
feet feet Proper pipe separation: Yes No
32
Total = ft Distribution box level: Yes No) / /f4
Systems located as permitted: Yes f No
Systems including plumbing stub -outs installed at proper elevation: Yes N
/ Y Average depth to drainpipe invert from finished grade: ° •inches Maximum depth• e2 Inches
Average depth of drainfield gravel: /6 inches Minimum depth of gravel AZ inches
Proper gravel size: Yes • No Gravel is suitable quality: Yes No
Backfill or fill material as squired: (Quality) Yes No (Quantity) Yes V- No
Date 7
TY PUBLIC HEAL UNIT
Note: Completed copies of this form will be provided to the applicant, installer and the building department.
Page 2 of 2
BUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building
MIAMI SHORES VILLAGE, FLORIDA
o PERMIT
D
Work to be performed under this Permit
Architect
Contractor
or Builder
Legal Lot
Description Bl.
Address of f ` Value of 1 Amount of
Building /i 1- ^ Project $ 1 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.
Signed INSPECTOR
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinance§ 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 ao
cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
p, j ' t
CONTRACTOR OR BUILDER 1 BY AUTHORITY AOZOT
N? 5167
DATE 19
Contractor's
License No.
Subdi-
vision
BUILDING
ELECTRICAL
PLUMBING
PERMIT N9 2649
Work to be performed/under this P mit
r r
Owner o `, t , i ' -
Building / �
Architect
Contractor
or Builder
i
Legal Lot t�� l� BI.
Description 4 �'. i
Address of �
Building r - i = 3 -
MIAMI SHORES VILLAGE, FLORIDA
Subdi-
vision
Value of
Project
DATE
Contractor's
, Licese No.
Amt. of
Permit
4.
. `194
a-
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 atoproved 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 nameckabove assumes the responsibility for a thorough knowledge of
the ordinances and regulations pertaining to the work covered hereby whether shown on the ifarrb -ea -ds Ww er.- en..ihe.staseoso►N -., cifiyikio d
that he assumes responsibility for work done by his agents, servants or employees.
Signed• .. By ,,
INSPECTOR l.w%"
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regula-
ions pertaining thereto and in strictconformity 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 my agent, servant or employee.
i CONTRACTOI(OR BUILDER r �
p BY' If
AUTHORITY