DRAINFIELD•PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 8#11 T. Job Address /b qj I / d . 96 'C - Tax Folio
Legal Description D 4 As Historically Designated: Yes /f No
'Owner/Lessee / Tenant MR 9 (O " 1-S /, ` Master Permit # 9, Z 3 , (f7)
Owner's Address /09/A16' ? S1$ Phone 7-51-' 1:2f21
Contracting Co. ,` j(. C) f P& , 2 r' �
,A Address ' gDx Co 132-3 �'
Qualifier J Ze /' //d C&.ki ss# 9 0. ' s7 7 5' I
State # 6 Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING ME HANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIP'T'ION ' '' 41 `� 'Gfir / d°t
Square Ft. 2 Estimated Cost (value) Nil i'M'
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 the;, stated.
Signature of owner and/or Condo President
FEES: PERMIT
RADON
Notary as to Owner and/or Con! 44' - t- -- -Date O -
�
My Commission Expires: �P� Y Pe
� i •
CC'.1E!C'7.., 7 • ..
C 7 77
F or o
Si ature of Contractor or Owner- Builder
Notary as to Contractor or Owner- Builder
My Commission Expires:
C.C.F. NOTARY 5 BOND &
Date
TOTAL DUE'S -Gs
APPROVED:
Zoning Building Electrical
Mechanical Plumbing Engineering
OF FLORIDA
'PARTMENT OF HEALTH AND REHABILITATIVE SERVICES
NSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
CON TRUCTION PERMIT FO
,[ m New System [ Al ` Existing System [ ] Holding Tank [ IY Temporary /Experimental
[ N Repair [ A Abandonment [ iti,ether(Specify)
APPLICANT: AGENT: 0 :., 1 ,cl r
PROPERTY STREET ADDRESS: /0 9 , ri 6_ .
LOT: 3 _ Ci( BLOCK: SUBDIVISION:
PROPERTY ID #:
0
T
H
E
R
SPECIFICATIONS BY:
- 3 d �6 !� ` [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
4 •• [OR TAX ID NUMBER]
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. 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 SPECIFICATIONS
T [ f ]AI ONS GPD] EP TIC TANK EROBIC 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: [ ]
MARY DRAINFIELD SYSTEM
SYSTEM
[ ] FILLED
[ ABED
D [ 2_ ti ]
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
[ ] STANDARD
[ ] TRENCH
I ELEVATION OF PROPOSED SYSTEM SITE [ 1 INC.ES /F ] [AB.VE /BELOW] BENCHMARK /REFERENCE P01
E BOTTOM OF DRAINFIELD TO BE ( ] 1 / [ABOV BEL0 J JENCHMARK /OFERENCE POINT )
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ .3] INCHES
APPROVED BY:
DATE ISSUED:
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (obsoletes previous editions which may not be used)
(Stock Number: 5744-001 - 4016-0)
[ ] MOUND [ ]
[
PERMIT #
DATE PAID
FEE PAID $ _571. c3
RECEIPT # /1e)-7
EXPIRATION DATE:
3
CPHU
` T7
Page 1 of 2
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.., _ .. Etio.15, CCqLGr :!e ^'J, lo'v- voIumc flush toilets, vr.7ance nrcvl:.^::.
:z s c inc viduui providing specification. :if designed ' y n ;egis:e_-ed engineer must be secleci.
C.
t- {uIL'h Unit (�. � J) personnel reviewing cod approving permit.
is issued by C2=sJ.
from du -e issued if the :;y tern has not been in :Aci led. ?eimits for system repairs become vole: 90 dcys from: he cc_e
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Notes:
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
,
)
if fe e 7471)
..")
Site Plan submitt d "by:
Plan Approved
ALL CHANG
SIGNATURE
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4015-6)
Not Approved
rid
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Date //6/72
County Public Unit
MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
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