80 NE 94 St (22)BUILDING
PERMIT APPLICATION
FBC 2001
Permit Type (circle): Building Electrical
Owner's Name (Fee Simple Titleholder) ./P � (% r
State r Zip 3 S J s
Owner's Address
City /?4j . (7
Tenant/Lessee Name
Contractor's Company Name
Contractor's Address
Type of Work:
Describe Work:
Submittal Fee $
Notary $,.��
Scanning $
Code Enforcement $
['Addition
lee,
❑Alterationn
7 c ).— r
Permit Fee $ I ?S
Training/Education Fee $ t i/ O
Radon $
k 71
Total Fee Now Due $ FEB p 5 PAID
(Continued on opposite side)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Master Permit No.
Plumbing Mechanical
Phone # Y i^
el ;72
Permit No. z ,2 FD`f - 3
Roofing
0
Phone #
Job Address (where the work is being done) PO !f - '7 <1 P L'f
City Miami Shores Village County Miami -Dade
Is Building Historically Designated YES NO
f"/ , (____ f _C;- /..11. Phone # '5
/f ' 31- ? " 2 - 1i2 . .
City j '• m1,, e State Zip i VI-
Qualifier
Architect/Engineer's Name (if applicable) Phone #
$ Value of Work For this Permit C
* * * * * * * * * * * * * * * * * * * * * * * * ** Fees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Zoning
Structural Plan Review. $
El New
1
t fJ et t)#% 1 7
Zip 3y1`; r
Square Footage Of Work:
El
! L9 !� Z
CCF $ / ?- P CO /CC
Technology Fee $ 93 7
Bond $ 3OD
❑ Demolition
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
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.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Chc 12/15/03
Owner or Agent
The fo egoing instrument was knowled ed before me this The foregoing instrument was acknowledged before me this
day of `r ...
NO 4., b '' ' _ day of �, ) , 20D / by M / ' ' ti hil �e
who is personally known
6 3 ,t7, to me or who has produced - F- V L, L who is rsonally known me or who has produced
E I ►► a,.011-/As identification and who did take an oath.
NOT • '' Y P :LIC:
Sign:
Print:
My Commission Expires:
Signature _ !/
NOTARY PUBLI
Sign:
Print:
Contractor
as identification and who did take an oath.
FlCIALNOTAAY SEAL
LA;.iSJVILiAR
9 j _ . � M`',OOMMISSIONEXPIR
mfi sti�1
My C' Expiresnn. i ooE_ _
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ** * * ** ********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY: / p' -U 1 Plans Examiner
Engineer
Zoning
02/05/2004 10:57
CO a TRUCTION DMRKIT FOR
E,)(] Repair [ /J
APPLICANT:
C 1 New System
r _
PROpHITY A,DDREs s i - 6: � a / '� / ct, r' h f . "� 3 / 3 `
E •% ca c .3
LOT& I r Z 1 _JLOCR:
PROPERTY ID S: l 1 2 v (o - L 1 3 -( 3 u
SYSTEM MfBT BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATSOItl9 AND STANDARDS OP SECTION ]91.0)65,
F.S., AND CHAP'T'ER G4E -b, P.A.C. DEPARTMENT APPROVAL OF SYSTEM DOSS NOT GUARANTEE t3ArTTSYACI`OI(Y
PERFORMANCE pOR ANY SPECIFIC PERIOD OF TIME. AMY CHANG1E IN MATERIAL FACTS, WRXCli SERVED :►S A
19ASIS FOR xssnANC13i OP THIS PERMIT, REQUIRE TRS; APPLICANT TO MODIFY THE PERMIT .ADPLIoAT.CON.
SUCH M0D /PICATTObT6 MAY RESULT IN PI'IIS PERMIT BEING MADE NULL AND VOID. ISSUANCE OP THIS PA'L11YT
DOES NOT EXEMPT THE APPLICANT PROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
RE T Z RIID FOR DS VELQPNINT OT° TITTS PROPERTY.
SYSTEM DES GN AND SPECIFICATIONS
S i LA:1
T (7 y G 1 GALLONS / CBPD SEPTIC TAME /AEROBIC UNIT CAPACITY
A ( 7 GALLODt3 / OPD CAPACITY
N [ ) GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM
K I rt ] GALLONS DOSING TANS CAPACITY [ ) GALLON& 0
D [ 2 0 6 ] SQUARE FEET PRIMARY
R [ - 1 SQUARE FEW
A TYPE SYSTEM: t STANARD
T CONFIGDRATTON: [ i T'Rbabictt
S LOCATION
Z ELEVATION OF PROPOSED SYSTEU
E BOTTOM OF ARAINPIELD TO BE
L
D TILL REGRIIRIi1}:
SPECIPICATXOM9 BY:
APPROVED BT:
DATE ISSUED: L Q
3056515610
3056515610
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONS2Tm SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Existing System
Abandonment
(4 . c, -,gyp
of BENC]•(ARR :
[ 14 ] 4 ( ] INCH.
DRAINPX$LD SYSTEM
SYSTEM
[ PILLED [ l
[ 4 RED 1 1
SITE ( . Q ] (1NCSRS /FT]
1331 l [ZNcaxa /Pr.]
fc
rimovz/linowl 882JC1»vk1C/ „
IABov /BaLow) BaMCmmAlrr/RRBP'It' t1 CE AU LINT'.
\ "
I { I - U I 2l4'CIIII>ti �\ C�
u I:m14. i.'+dlroM r _•_ - -- -
•
EXCAVATIOlt REQURY,D
Du 4016. 12/99 (Page 1) (Previouo Editions
ttEPIR
sBD rVI S I olq
MR C SEPTIC DRAIN CO
(1"1 Temporary
May Be Need}
Molding Tank
pEltxzT INO. 42 4 e -a0Z1
DATE PAID:
PaB PAID1 r
PICSIPT 0, '
1 3 •- r C'
=
t ��l
[ 1
Innovative
PAGE 01
/ SA arTC L',ar -1 r d.
['SECTION, TOWNSHIP, RxNGS;, Pi.ACAIL NO2421RR]
IOR T'AI I NUM81121
1d0UND t 1
PROF.ti)sLi) '. Es SC iCf'_ ION ea> Uit
__27TLZ: t .
MULTI - CRAMBRRED/I:!N- sERxe9 1 1
MQLTr•GxAMDE1t1iI) /YW- SERIEE i ]
CAPACITY SINGLl1 TAM 1150 GALLCN81
K ] D09118 PER 24 ERs 4 Pus [ I
Part 1 • Heitth Department
Part 2 - App$ }Cant
Part 3 lnsIeft r /GantrrCtor
P•. r A o .
1 — 1
Page I of 3
BX*IRATSoN DATS: "� J3
' 02/05/2004 10:49 3056515610
Scale: Each block re • resents 10 feet and 1 inch = 40 feet.
■O■ ■O■ ■ ■ ■ ■O ■ ■■ ■ ■ ■11 ■ ■ ■■ ■11 ■■
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■■ MIME ■MUMMI '■MEEMME ■ ■ N ■■■■
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Notes: 75
Site Plan submitted
Plan Approved .�
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number 3 1---/j_. 9'
• zvrl ra.!
Dm 4015, 10/96 (Replaces HRS -H Form 4016 which may be used)
(Stock Number: 5744 - 002 - 4015 -6)
MR C SEPTIC DRAIN CO PAGE 02
PART II - SITEPLAN
At
Not Approved
E 1
CV rk
A a: e
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
D
County Fealth Departmen
Page 2 of
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204 Permit Number: PL2004 -38
Printed: 2/9/2004
Applicant: RENE
Owner: ECKERT
JOB ADDRESS: 80
Contractor MR C'S SEPTIC TANK
Local Phone: 305 - 651 -7859
Parcel # 1132060130300
Signed:
NE 94
(INSPECTOR)
Plumbing Permit
ECKERT
RENE
ST
Contractor's Address: P 0 BOX 693239
Page 1 of 1
Legal Description: MIAMI SHORES SEC 1 AMD PB 10 -70 LOT 1 & LOT 2 & E1/2 OF LOT 3 BLK 3 LOT
Fees: Description Amount
FEE2004 -1220 Building Fee $175.00
FEE2004 -1221 Builders Bond $300.00
FEE2004 -1222 CCF $1.20
FEE2004 -1223 Notary Fee $5.00
FEE2004 -1224 Scanning Fee $3.00
FEE2004 -1225 Technology Fee $4.37
FEE2004 -1226 Training and Education Fee $0.40
Total Fees: $488.97
Total Fees: $488.97
Total Receipts: $488.97
P4 Z--s._
Permit Status: APPROVED Permit Expiration: 8/3/2004 Construction Value: $2,000.00
Work: REPLACE DRAINFIELD ONLY
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 responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
Date
Legal Description
( �wn 1 Lessee / Tenant (li LL 7 _)ir
7® te E
Owner's Address
Contracting Co. f :0-c
� Address I7 ' t( to a) :2q ti
Qualifier 1.�LL ) b SS4 /__ Phone 6 t
State # C567 Municipal tt Competency 4,` J') SUS Ins.Co. „(71
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICA. PLUMBING CHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
i7 IJ �� s�
�S Job Address Tax Folio
Square Ft. Estimated Cost(value)
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 informa ion is accurate and that all work will
be done in compliance with all applicable laws regulating
authorize the above -named contractor to do the work stat
k
e of owner and /or C do President
Signat
Date:
Pa ���
otary ,rN1141 . President
My Coll - 5,1 = &gitielTatp MONTIEL
COMMISSION NUMBER
a , ;ql,s Q CC401261
** * ,�� ` ' D � � a COMMISSION
*AUG M7 1998* * *
FEES: PERMIT ;L ° RADON
APPROVED:
Zoning
Mechanical
*
Date:
Notary
My Co
NOTARY
Master Permit # 3 7"11
struction and zoning.
re of Contractor or Owner- Builder
a ,pmefl ovarlewO r -Builder
p cO
a M MONTIEL I
:. sION NUMBER
(./2, Q CC401261
71 ;‹, " j MY COMMISSION .EXP.
* *r rt 0 * AUG* 17 1Qla * **
- - - -- - ) � ...._zs.�. fit.
TOTAL DUE , j ) e
*
C.C.F.
Fire Other
Phone
rthermore, I
Building Electrical
Plumbinge" j Engineering
CONSTRUCTION PERMIT FOR:
[, ] New System [ 1 Existing System [ ` } Holding Tank [/' ] Temporary /Experimental
] Repair ['` ] Abandonment (/ Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
T [
A [
N [
K [
D [ 1: SQUARE FEET'PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: [ ] INCHES
0
T
H
E
R
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
BLOCK: SUBDIVISION:
L ( /M/<
AGENT:
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ ] BED [ ]
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 -0)
EXCAVATION REQUIRED: [ ] INCHES
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
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.
] GPDI SEPTIC TANK /AEROBIC UNIT CAPACITY 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: [ ]
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
TITLE: CPHU
EXPIRATION DATE:
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit trackin3 number assigned by CPHU.
APPLICATION FOR: Check type of permit, if °Other° specify type in blank.
APPLICANT: Property owner's full name.
TELE? ONE: 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 HDM: 27 character id number for property. (CPI- may require property appraiser ED tl or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1OD-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 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 #:
SITE EVALUATED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK:
SITE SUBJECT TO FREQUENT FLOODING:
10 YEAR FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE 1
OBSERVED WATER TABLE:
ESTIMATED WET SEASON WATER TAB
HIGH WATER TABLE VEGETATION:
SOIL TEXTURE /LOADING RATE FOR
DRAINFIELD CONFIGURATION: [
REMARKS /ADDITIONAL CRITERIA:
PROPERTY SIZE CONFORMS TO SITE PLAN: ( i
TOTAL ESTIMATED SEWAGE FLOW:
�.,.
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE: tvi ( a
INCHES [ABOVE /
LE ( ELEVATION:
[ ] YES ( , � /40
Munsell # /Color
USDA SOIL SERIES:
Texture
Depth
to
to
to
to
• O
t •
to
to
t0
SUBDIVISION:
HRS-H Form 4015, Mar 92 (Obsoletes previous ediiions which may not be used)
(Stock Number: 5744 - 003 - 4015-1)
AGENT:
PERMIT #
[Section /Township /Range /Parcel No. or Tax ID Number]
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.
YES [ ] NO NET USABLE AREA AVAILABLE• ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 25 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: (: %' , ' SQFT
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABOVE /BELOW} - BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACKAWHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES :,
SURFACE WATER: FT DITCHES /SWALES: FT NORMALLY WET? [ ) YES [ Vio
WELLS: PUBLIC: �, > FT LIMITED USE: k - `a FT PRIVATE: A FT NON - POTABLE:_ FT
BUILDING FOUNDATIONS: FT PROPER INES: < a FT POTABLE WATER LINES: FT
[ ] YES [ NO
FT MSL /NGVD SITE ELEVATION: _ FT MSL /NGVD
BELOW}' EXISTING GRADE. TYPE: LPERCHED / APPARENT]
/2 [ ABOVE /„BELOW 'J EXISTING GRADE.
MOTTLING: [ ] YES [) /NO DEPTH: INCHES
/'
/ / - DEPTH OF EXCAVATION:
SYSTEM SIZING: � r ` ' , . , ! ; j,
TRENCH ( ` BED' [ ] OTHER (SPECIFY)
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
fA
to
to
to
- to
to
t0
too.
to
to
USDA SOIL SERIES:
10 YEAR FLOODING? [ ] YES [ j NO
! r
INCHES
Page 3 of 3
INSTRUCTIONS:
PERMIT at Permit tracking number assigned by CPHU.
APPLICANT: Property owner's full name.
ACcE1',i': Property owner's legally cuthor3z d t:: p:K:ct;.�2ntive.
BLOCK, SU3D V iS.•.ON: Lot, block, and subdivi_ ion for !ot.
?3o?a",7Y IDO: 27 ch.... -r °;r number for i:opc t:;?prcic:r u' os LecticnJtzwas sir /:.c.;;.; /;;;:.icul trcnt3ce)
t:ilecl_ ,role :y L ZO ., ...'P, CCRn ,_ _.. to •_..._a ned cit. plan. . :cc .] : __ . :; c -_. _., a :; .f y"3 c_
r li p. v::.' :":'"era L �_.:r_:,:r, :.� t, •se6:s wi'_: • = fablie L;g:"s' n -o tJt.y o,: ecr ^: -c:__ :. is a.tC:::: iv:; of •
normally v!ct drain.Lrz c. _r. ec, mr, no or e:he:' a:'.C:] bodies oT water.
ifNDlJib SETI3F>^,:eS:
ab: rrJ'tU 7. “.. ......_'.
::hap . O E.C. '.S: C itzo.:..ti LCtC _ ^.Y' , LT_k': w C 7i'i Fi C ;., t
3 . : location o'i;:.dbeaeha:c_:.. :'^:..'r _.-vc;o.'a e`2_;_:,'t .., td'
elevation of tile proposed system Cite h e`_c. or (abevc o: b.^,la J) to ::lc
Record ninimum setbacks which can be me:^ to cli listed features. Acts ai ^ ^asurtm:s:; :mist 'ac: card:;c o: "NA'
ar non applicable features. Fezt:i n: oz sito plan or within 75 f:et of :h:1 applicant !c= . "' ::i 'et; mecc;:eed. :: Iscatie 9
of any public drinking well within 2C0 feet c'tho applicant's lot tut: clan b; veri et:.
FLOOD INFORMATION: Record information on lot's subject to fiooding. For lots Lubject to flooding rcco;d if) year flood elevation fez cite and
actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed abcorptior area to a minimum depth of 6 feet c:• r +aa1 r,ra Soil
identification will use USDA Soil Classification methodology (l unceli colors and USDA coil textures). t2cfusela mutt
be clearly documented. Provide USDA soil seriea if available, record °UNK° if the aeries cannot be determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched' or "apparent' ca
appropriate. Record the estimated wet season water table elevation bated on aite evaluation, USDA coil maps, and
historical information. Indicate if there is high water tab': vegetation p:'ec2nt. L^i.icrt: if mci.Iing in present and depth.
SOIL TEXTURE: Record soil texture or loading rote for sy ^'e :: 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 additions! remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professionni engineers must teal all documentation submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT TS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ +] SHOT: H.I. H.1. H.I.
H.I. ' [-] SHOT [-1 SHOT [-] SHOT
APPLICATION FOR:
[ ] New System [ ] Existing System
[ ' [ ] Abandonment
APPLICANT:
AGENT:
MAILING ADDRESS:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
BLOCK:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
• ? ' 7
[
-
SUBDIVISION:
L'L
No. of
Bedrooms
APPLICANT'S SIGNATURE: / /
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4015 -1)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[ ] Holding Tank [ ] Temporary /Experimental
[ ] Other(Specify)
TELEPHONE:
RESIDENTIAL [ ] COMMERCIAL
Building # Persons
Area Sqft Served
DATE:
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]
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
ACRES [Sqft/43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ]'PUBLIC
Business Activity
For Commercial Only
[ ] Garbage Grinders /Disposal [ ] Spas /Hot Tubs [ ] Floor /Equipment Drains
[ ] Ultra -low Volume Flush / ilets //[ - Other (Specify)
i' / 1 t
Page 1 of 3
ACAiCN FO: Chet's type of permit, if "Cthe:' specify type in blank.
A?. f.'.AN7: ?roperty owner's full narne.
'7elenhone number for cppIiccn o cgent.
AV; ?raptray owner's legally cuthorized naprerontative.
DRESS: 'cox or :arzet, city, t rd ;sip cmla cddrorc fo:cpplienr:t or roar:.
L.ot, bocz, End subdivision fo: lot (rocmxind or umecordesl ClibeiViai011). f IC: i3 not c .reco:rlt subdivision, c. copy of the lot
legal description or deed must ha citrched.
C7 Official ricte of subdivi:lion c& cpproved
lot into :wo or more pc:ceic pl.:Ty c:::::/oyi.:1■3 7:::; coral:La:as: "...ho
'AC 2.7 r:::::rentet. nu:nbec . -- ;-. . cpr.':colr(::.,:: 0 e: nv.mlzar.
N:t usable ct of pro?::: ir re:Las ortelucivo _
'ace!: within ?Calk Of wry o: rntcicsiv,:. :. , - .;.T.„1‘..;;;, 0.7
ic7 bodies of wate:. Contiguous u.npavoci co rl noncom.pretee: C'fit%! rit ouhrcc. obstructions
may ha includer:, in calculating lot a:en.
Check private o: public.
ADDRESS: Street address for property. or lot without en assigned street .ddress, indicate street or mad cr:d locale in county.
DftlECTlONS: provide detailed instructions to lot or attach an ret n thawing lot location.
:NFORMA`t'ION: Chet% residential or commercial.
':oltt type of establishment from 'llate Chcpte: Excmples: ringia :!n0 wco mean castcurcnt,
doctor's office.
D. ::Jams : Count all rooms designer! primarily 1): sleeping cad those r.:acs et:petted to routinely provide i:aping cocor:::notictions for
occua:mt.4.
AREA: s.gul.ra footage of enclosed Habitable crou. o" eiviellin excluding, crrasa, ecrport, 09C11 r fwTly
cr,;end patios or deem. rased on outside mess,unamenta for ecela stmy of arceltirc.
1 of persons maidirg, 0: tas:chlithr. ;Fry: :asidontici estchlishment, 7 Z.:Ca hod:oz.:a r.:a
cssume.d.
r.pplicciions only. C of ope:r.tion, o: 3:12e: inliTcfnction
f.:htoter 10D-6, :FAC.
Marc er eh listed fixture with nu.nbe: installed or "NA" if no: r.nplicclaie.
Signaturo o r,pplicant rpniicatic c rolr.y 'till cpprop:Is:o 7G:a. rnri
, ;aserr ants, Fiy L' •:;„•; 1.". • • '; :': • •",'" '
oGii■ c • •--,
203
lioo-
.• 1 .00: ..•
c
" • - . •
• • ,-, ."„
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCtI9JsL PERMIT
Permit Application Number 7
Scale: Each block represents 5 feet and 1 inch = 50 feet.
i 11 1 1 1 1 1 1 1 11 '! 11 1 _1 , 1 Him' I 1_ I I I
I I 1 ill, I ' I �_ I_I 1 ! I I I 1 1 1 - I - 1 1
X 1111 1 iI� 11,1
i I . 1,, � , I1 III 1 1 1
I 1! 1 I_I I _1 1 !( 1
1 1 1 1_f l 1 1 1 1 11' 1 1
I I I 1 H I' 1 1
III i i i j 1
,1 1 11,1 11
1 1 1 1 1
Notes:
Site Plan submitted by:
Plan Approved
PART II - SITE PLAN
i I
I 1 1
1',
1 I
1
II
I I
1 1 I I�I
I ,1, I /-
1 1 1 1 1 1 1 1 i 1 1 1 1 1
SIGNAA4JRE TITLE
• Not Approved Date
County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4015-6)
Page 2 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
-_ - PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Site Plan submitted by:
Notes:
SIGNATURE TITLE
Plan Approved Not Approved Date
B County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015 -6)
r I
Page 2 of 3
/16
i' Crash No
Appiieatiom is hereby mane for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
atructie-e l; erein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
buildixg during progress of work.
Owner's Name and Address _P! 4 ii ° 10422. No. v . G� _ ! - !' ' - Street / f / ,,,
Registered Architect and /or Engineer _____ _ (� __
Employing Plumber's Name. __ -- _ _ !�_��_`L� _La � D1' 221 _L Street 4 VI
Location and Legal Description Lo ________________—__ _Block // Subdivisi
Street and Number where work is to be performed —No * f) r [ / • 1 , Street 91_,:__
State work to be performed and purpose of building (By Floors)__
New Building — __ Remodeling _______________.____ Addition_______._________.__. Repairs No. of Stories. _ .._._.
Size Septic Tank .......
_-__ -
Feet of Drain Tile 19
Amount of Permit $
STATE OF FLORIDA,
COUNTY OF DADE. j
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
( Signed)_
Date
Lf-10-6/
My Commission Expires Notary Public, State of Florida
T of Tank_ Capacity Gals
; e . Feet of Tank or Drain Field from Well
Nature of Water Supply: City— Well.______________ ..... __________ ....... ____ ____Size of Soakage Pit
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts If obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida P rfianent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are
required by the Act The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
lid by Miami Shores Village.
(Signed). l_ _ , ° TAA.C4--
r / faster Plumber.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•neoessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
TUBS
TUBS
SHOWERS
LAVA-
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT'NS
TOTAL
FIXTURES
CONTR.
LIST
CN6ICK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SWIM'G
P001.
Ceara*. LIST
C•RCK
/16
i' Crash No
Appiieatiom is hereby mane for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
atructie-e l; erein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
buildixg during progress of work.
Owner's Name and Address _P! 4 ii ° 10422. No. v . G� _ ! - !' ' - Street / f / ,,,
Registered Architect and /or Engineer _____ _ (� __
Employing Plumber's Name. __ -- _ _ !�_��_`L� _La � D1' 221 _L Street 4 VI
Location and Legal Description Lo ________________—__ _Block // Subdivisi
Street and Number where work is to be performed —No * f) r [ / • 1 , Street 91_,:__
State work to be performed and purpose of building (By Floors)__
New Building — __ Remodeling _______________.____ Addition_______._________.__. Repairs No. of Stories. _ .._._.
Size Septic Tank .......
_-__ -
Feet of Drain Tile 19
Amount of Permit $
STATE OF FLORIDA,
COUNTY OF DADE. j
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
( Signed)_
Date
Lf-10-6/
My Commission Expires Notary Public, State of Florida
T of Tank_ Capacity Gals
; e . Feet of Tank or Drain Field from Well
Nature of Water Supply: City— Well.______________ ..... __________ ....... ____ ____Size of Soakage Pit
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts If obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida P rfianent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted' for inspection on the site of the work such public notice or notices as are
required by the Act The undersigned agrees to employ only such sub- contractors, on work to be performed under this permit, as are
lid by Miami Shores Village.
(Signed). l_ _ , ° TAA.C4--
r / faster Plumber.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made•neoessary by improper notice for inspection, or faulty
materials and /or workmanship.