1065 NE 97 St (8)■
'MIAMI SHORES VILLAGE, FLA.
JOB
ADDRESS /0 (' - / ,
INSPECTION
TIME READY
N? 6143
REMARKS:
•
INSPECTOR DATE
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FORS
[' /] New System (G p] Existing System
[L1 Repair [Z] Abandonment
APPLICANT:
PROPERTY ADDRESS: ` " �� �= "
LOT:
BLOCK: d ® SUBDIVISION:
PROPERTY ID #: � Q c > � 6 G ,;3
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T
T ( /() ] GALLONS / GPD 4pTreTAN yAEROBIC UNIT CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM
R [ ] GALLONS DOSING TANK CAPACITY ( ]GALLONS CO [
.
D e .i ''
( ] SQUARE/ FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET /�( SYSTEM
A TYPE SYSTEM: [ ?] STANARD [ FILLED
I CONFIGURATION: [A ;] TRENCH [7] BED [
N '
F LOCATION OF BENCHMARK: h i, P S "?
I ELEVATION OF PROPOSED SYSTEM SITE [D• I gC] [INCHES/
E BOTTOM OF DRAINFIELD TO BE ( ,' & / ] (IH,E /FT)
L
D FILL REQUIRED: [Z� -YY ] INCHES EXCAVATION REQUIRED:
0
T ~ �
H
E
R
SPECIFICATIONS BY:
T
APPROVED BY:
T t-4 t pJv
DATE ISSUED: ( i '- VI
DH 4016, 12/99 (Page 1) (Previous Editions May Be Used)
(' 43 Holding Tank (1 Innovative
[l Temporary ['
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
1 MOUND
MULTI- CHAMBERED /IN- SERIES [ ]
MULTI- CHAMBERED /IN- SERIES [ ]
CAPACITY SINGLE TANK: 1250 GALLONS]
] DOSES PER 24 HRS # PUMPS [ ]
[ABOVE /BELO BENCHMARK /REFERENCE POINT
[ABOVE / LOW BENCHMARK /REFERENCE POINT
[ c 0 ] INCHES
TITLE:
TITLE: r c ` l
pi. 2: iw7Cccni
7i. E. Insiciler /Con4rac•o•
IJu]cinc i)coerim
PERMIT NO. O// _ '-
DATE PAID:
FEE PAID: EJ
RECEIPT #: o
EXPIRATION DATE: ;
Page' 1 of 3
d
INSTRUCTIONS:
PERMIT NUM : ER:
CONSTRUCTION
PERMIT IF 6Y:
APPLICANT:
TELEPHONE:
AGENT:
MAILING ADDRESS:
SYSTEM DESIGN AND
SPECIFICATIONS:
Permit tracking number assigned by CP U.
Cheek type of permit, if "Other" specify type in blank.
Property owner's Tull name.
Telephone number for applicant or agent
Property owner's legally authorized representative.
P.O. Boa or street mailing address for applicant or agent.
v .
•
LOT, BLOCK, SUBDIVISION or
PROPERTY IID #: 27 character id number for property. (CIIID may require property appraiser ID # or section/township /range/parcel number)
TANK: Minimum specifications from Chapter 64E-6, PAC.
DRAI{NFIELD: Minimum specifications from Chapter 641E-6, IFAC.
OTHER: Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. IIff designed by a registered engineer must be sealed.
APPROVED BY: County ]Health Department (CEO) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CR110
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 by:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN
Notes:
SIGNATURE TITLE
Plan Approved Not Approved Date
By County Public Unit
HRS-H Form 4015, Feb 85 (Obsotetes previous editions which may not be used)
(Stock Number: 5744- 002 - 4015 -6)
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
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