92 NE 95 St (5)Qualifie
State # S n o 9C2M
WORK DESCRIPTION
Square Ft. 10 0 th
Notary as to Owner
My Commission Exp
APPROVED:
Zoning
Mechanical
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 1 ) -4 00 Job Address C I a k) (2( Tax Folio
// ✓ 3ocopoLO
Legal Description ) Ji b m'AHii oricall Desi
Owner/Lessee / Tenant -- Do1, ( • 1 p S R o rfl 4, )u) K
Owner's Address 1l !J� - Phone
Contracting Co. t� T� C ,� : l , ddress toa- )
SS# gOPhone (4)0 STS Lai?
Competency # Ins. Co.
Municipal #
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
er andlor Condo President ` - Date
k — )7� f - 3
ARYSEAL
YS J VILLA?
TARY PUBLIC STATE OF FLORIDA I
COMMISSION NO. CC714103
MY COMMISSION EXP. MAR. 12002
O
FEES: PERMIT j7 RADON
C.C.F.
vv
I'Ie IG't
Estimated Cost (value)
Yes No
f
Master Permit # `F t 7
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 ed.
Signa
Notary : to Con
My Commission
OFFICIAL Y EAL
xpires es: GLADYS I VILLAR
NOTARY COMMISSION SION NO. CC7L 10
MY COM_41._N EXP. MAR. t 02
Electrical
• BOND
TOTAL DUE
� -/ -Zam
Date
/_ /y_ 2.00 v
Structural Engineer
CONSTRUCTION PERMIT FO;t:
[ tj New System [ 4.Existing System ( ki Holding Tank [ /Al /Temporary /Experimental
(. Repair (tJ/ Abandonment ( /,..]"
APPLICANT:
PROPERTY STREET ADDRESS:
LOT: BLOCK:
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
T
A
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LOCATION OF BENCHMARK:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL S
CONSTRUCTION PERMIT
Authority: Chapter 381,
CA
SUBDIVISION:
;Gad] [GALLON ( :GPJ SEPTIC TANK /AEROBIC UNIT CAPACITY
[ : 00] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
( ] SQUARE FEET
TYPE SYSTEM:
CONFIGURATION:
SYSTEM
[ .„, STANDARD ( 41 FILLED
[ TRENCH [ / BED
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE [
AGENT:
FAC
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
ti
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.
MULTI- CHAMBERED /IN SERIES:[ ]
] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[
] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS PER DOSE DOSING TANK CAPACITY DOSE.RATE [ ] PER 24 HRS NO. OF PUMPS:
(]
[ it MOUND
[ /1
,., [INQfSH /FT] [ABOVE /BtILOW)JBENCHMARK /REFERENCE POINT
] [INC /FT] [ABOVE /BE:Mr BENCHMARK /REFERENCE POINT
FILL REQUIRED: [ k iill INCHES EXCAVATION REQUIRED: [ INCHES
*VW. LOAMY COARSE SAND
TINDER BOTTOM OF DRAINFIELD
tN a�Rt EL.
(page A T10N1
9
SHE SEPTIC TAO SW: .
DH 4016, 10/96 (Replaces HRS -H Form 4016 a e 1 1 wh' y1
) ��1I DE IC Il�,°�,TALLLI) LAl t]1i+ r,..1-�I.J
(Stock Numbr: 5744- 001- 4016 -0)
� .,.(
/ �-
PERIMETER OF EXGAVATION AREA SIIAIL RE
AT LEAST 2A FEET N]DER ANO LONain THAN T
PROPOSED ABSO�INTION KR A DRAIM TRENC
TITLE:
TITLE: CHD
t>
EXPIRATION DATE:
-.s
=` -• - We SEPTIC TANK SHALL SE PUMPED AND A SOLIDage
TION DEVICE INSTALLED ON THE OUTLET TEE
1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICATION FOR: Check type of permit; if "OTer" 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 10D -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 1OD -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.
+ •
Site Plan submitted tiy:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number =
Scale: Each block represents 10 feet and 1 inch = 40 feet. 1
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Notes:
re 4 / • 1,4/
DH 4015, 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-6)
PART II SITEPLAN
1 4
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
e „ #
',.:,t 4 ‘;'''). 1 _4" if
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.77- '+' w• 1 . , ''' 'I -- 1 ,,,
4i " , , V
Plan Approved Not Approved Date
By County Health Department
Page 2 of 4