930 NE 95 St (11)Date i - Q -72- 4C 1 Job Address
Owner / Lessee / Tenant
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Legal Description
Owner's Address ollo �,� S S '(
Contracting Co. AA 7 v St.t Lt-L- 1
Qualifier
State # Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL P NG MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION /4-z- e. -.'►1 reC I1AJ 7/i G/G_ zOe
/� 00 >p
Square Ft. °� - Estimated Cost(value) <O ��
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 i curate and that all work will
be done in compliance with all applicable laws regulating cons - on and zoning. Furthermore, I
authorize the above -named contractor to do the work stated.
Sig` ^ ture of Contractor or Owner- Builder
Da
Signature ofor Condo President
v
‘30 ,/fit q sJs
Tax Folio
Address 6 �o�� S
ss# Phone q L/ L / ' O" ' �
•
Master Permit # .32D
Phone
N(o '"
`arj 44,4,toog•gypMA;71g er- Builder
My ;C. :n sBl1plsI TIa
Z ;w * Co MISSION NUMB
t .'4.;... *t CC401261
▪ ' nQ MY COMMISSION EXP.
* * * QF f \ AIOG. 17M998 *3.
* **
FEES: PERMIT g(/W9 RADON C . C . F . 2 0D NOTARY 5 TOTAL DUE gie
APPROVED:
Zoning
Buildin
Mechanical Plumbin
Fire Other
Electrical
Engineering
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
W'TRUCTION PERMIT FOR:
[1 :] New System [P (Existing System
[ ] Repair [V] ] Abandonment
0 A
APPLICANT:
1 o �E7/"�t°
PROPERTY STREET ADDRESS: C if '�
f
LOT:
PROPERTY ID #: ,/
BLOCK: SUBDIVISION:
[ Holding Tank
[/'] Other(Specify)
AGENT:
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -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 SPECI ICATIONS
T [6 /) 1 <GALLO/18 GPD] TAN4C /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
A [° ] [GALLONS / 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 [ ' ] SQUARE FE[',1� PRIMARY DRAINFIELD SYSTEM
R [ ] � S UAFRE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED
I CONFIGURATION: [ ] TRENCH [ ] BED
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [
L
D ] INCHES EXCAVATION REQUIRED: [ ] INCHES
0
T
H
E
R
FILL REQUIRED: [
/1
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
c 4
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 - 0)
PERMIT #
DATE PAID
FEE PAID
RECEIPT #
r t Ff ?6 3
ff /' � ��U,f
Usf] Temporary /Experimental
rye, oft
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
APPLICANT
[ ] MOUND [ ]
[ ]
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXPIRATION DATE:
y
[
CPHU
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number assigned by CPHU.
APPLICATION FOI<: Ch: ck tyre of perrii , if `Other` specify type in blank.
A?PLiCANY: Prc,perty owner's full name.
TELEPHONE: Telephone numb. for applicant or agent.
AGENT: rr::perty oc :ner'c iegal!y authorized d reprerentrtive.
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. (CPHU may require property appraiser ID # or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
W
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 Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPHU.
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.
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
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:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE
SURFACE WATER: ; J FT DITCHES /SWALES:
WELLS: PUBLIC: FT LIMITED USE: , FT
BUILDING FOUNDATIONS:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ -1'NO
10 YEAR FLOOD ELEVATION FOR SITE: E' FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color
USDA SOIL SERIES':
Texture
Depth
___L __to
to
to
to
to
to
to
to
to
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [ - T - BED
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY:
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used :,;
(Stock Number: 5744-003-4015-1)
AGENT:
PERMIT ,#
SOIL PROFILE INFORMATION SITE 2
[Section /Township /Range /Parcel No. or Tax ID Number]
I YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
PRO ?OSED SYSTEM TO THE FOLLOWING FEATURES:
FT NORMALLY WET? [ ] YES [] NO
PRIVATE: `+ FT NON - POTABLE: FT
FT PROPERTY LINES: FT POTABLE WATER LINES: FT
10 YEAR FLOODING? [ ] YES [ ] NO
SITE ELEVATION: FT MSL /NGVD
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE; _ INCHES [ABOVE / BELOW) EXISTING GRADN. TYPE( [PEIRCHED'/ APPARENT],
ESTIMATED WET SEASON'WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
DEPTH OF EXCAVATION:
[ ] OTHER (SPECIFY)
DATE:
INCHES
Page 3 of 3
r3C .t
•,r
•
APPLICATION FOR:
[� ] New System
[ ] Repair
APPLICANT:
AGENT:
MAILING ADDRESS:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
1
2
3
4
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
BLOCK:
[1,1
[
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
APPLICANT'S SIGNATURE:
Existing System
Abandonment
4F'Ak Etta
SUBDIVISION:
Unit Type of No. of
No Establishment Bedrooms
[ Garbage Grinders /Disposals
[.. ` ] Ultra -low Volume Flush Toilets /
/;///
[� l
BUILDING INFORMATION [,,j
Building
Area Sqft
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4015-1)
[
] COMMERCIAL
PERMIT # %' <' . • :
DATE PAID 1
FEE PAID $
1
RECEIPT #
TELEPHONE: /,,
DATE:
•.;.,
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
•
Holding Tank [i] Temporary /Experimental
Other(Specify)
# Persons Business Activity
Served For Commercial Only
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
ACRES [Sqft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC
(.1 Spas /Hot Tubs (,.) Floor /Equipment Drains
[.,AA Other (Specify)
Page 1 of 3
C11k type of permit, if 'Ot.I.ter“ specify typo
L':operty owner's full name.
numbe:: foy applicant or agent.
ownerh: ant.!lorized
ere?y 7ct
. description dend
1;1'ficirl rot:ardor: ::.r,
into T,13/0 f: • 7'.3•7; of en:rs!dored L
7•J.i "70 '3:7.: 777; --/
: :..:-.--: 'ken: •
:.:54 -- "71 :3!•" , :
Check private or public.
Street address for propr.rty. ,To: lots without an assigned alreet addrnss, Indies:to: otree::: race and lcsals. enu.nly.
Provide eh:toiled instructions to lot or attach arr ar0c sap allowing lot location.
reside:itial or commercial.
0 -
type of establishment from c. iiixan.,:: single fonlIly, sin3le wido
doctor's office.
NO. 3:-.1):100iVlS: Count all ro Irns designed primarily for sleeping end those areas expected to routinely provido rleeping ceco=cedations fcr
occupants.
ATtrri_1":: . ':•!r.bitsble arcs. of dwelling uni:, garr.ge, er.Terxt, frlly
eel e p::.. . outside :110E:11. fOl* 0.£1027_ r...0"1/ Of :31•7aCiL!3'0.
N'..1111 • ' ;• . - or v., c
SINT.SS k C \ • onl! . .!St ouic of ern.ployeel., EI•7.e.1•:C•2.7. of operation,
'fable II, Chapter
: :1t cad d f:•:turc ;T.:in:her installed or "NA" if not applics.ble.
L.:: 1-uo,nittce, to the fees corZ ottaclpinfints.
- _ - ,:nidrneer. C.' ',31).1'rP., cvi hi 11:30 . .
.. , 7:0_17 0:
;.• :30 (.'JT f
pe!I:11; 0.•!. arljr.corr. pr: :e \. 0"7 C.13•27..i.f.":•.:..2.
lu'olic vf1 wit.lain 200 ft of lot.
of
ty}es, C.L
71..:Cf.'1313:•.: con7.7or!tio2 clut:ntlIy of l-Yr.r.:0V/EI:e::.
Scale: Each block repraents 5 feet and 1 inch = 50 feet.
I I Ii!
I I k±
Site Plan submitted by:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
• Permit Application Number 4 `� W:'
Notes
�
PART II - SITE PLAN
SIGNATURE
Plan Approved Not Approved
By
/
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS-H Form 15, Feb 85 (Obsoletes previous editions which may not be used)
TigEk Nu5144 -002- 15 -6) r.
TITLE
Date
County Public Unit
Page 2 of 3