Drain FieldDate I a'L 1 c ; Job Address
Legal Description
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
1' a o, /.16 g6 S
Tax Folio
Owner / Lessee / Tenant E i.S Master Permit # 374/SC2
Owner's Address 1209 hlC- S ` Phone 89a - 6°63 --
Contracting Co. � S r4•Address /q 932 "i4-4
Qualifier sail t'., /C ss# ° (?c s) 6 S 1 - 747 51
State #/:- Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
e`t_'Q CY O iQ I6Q
Square Ft. 3o0 Estimated Cost(value) 12 0
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 ' ompliance with all applicable laws regulating construction and zoning. Furthejw: re, I
author he above-named co ractor to do the work stated.
or Condo President
No s to Owner or Condo Pres dent Notary as to Contractor
My Commission Expires: LORNA My Commission Expires:
OOn m Pti S 161 2 2,199 8 A llyOMMM 22.1996
MyCam. ��,� : MerZ 199
N o. •.K :.0.! ,
** * * * * * * * * * * * * * * **
of ) ate
FEES: PERMIT RADON C.C.F. /. NOTARY
APPROVED: Fire Other
Zoning Buildin
Mechanical Plumbin
Signature of Contractor o
Date: -2 27 J9J
er- Builder
TOTAL DUE •
Electrical
i ngineering
STRUCTION PERMIT FOR:
] New System Existing System
] Repair ] Abandonment
Tank
olding ] Temporary/Experimental
g [ ]
Other(Specify)
APPLICANT: ® GENT: ;
A. °--/,?,...,,4. Arm i .. ' 0 le IL
PROPERTY STREET ADDRESS: / O /, S f
LOT:
PROPERTY ID #: i 4/ , d 4
G �
H r
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: ,_
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK: SUBDIVISION:
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.
P P
SYSTEM DESIGN AND SPECIFICATIONS
T ] GALLON GPD] SEPTIC TANK /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 ?Pn2 ] SQUARE FEET RIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
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 ( ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
TITLE:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0)
APPLICANT
TITLE: �
PERMIT # Ine..
DATE PAID" .;
FEE PAID $
RECEIPT #
f--T& CPHU
EXPIRATION DATE: 2.
Page 1 of 2
APPLICATION FOR:
[/'New System
[ ] Repair
APPLICANT:
AGENT:
LOT:
PROPERTY ID #:
\PROPERTY SIZE:
BLOCK:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
1
2
3
4
1
1
APPLICANT'S SIGNATURE.:
•
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
[ ] Existing System [ ] Holding Tank [
[ ] Abandonment [ ] Other(Specify)
UA C lei lo
M C < ��,•, `
MAILING ADDRESS: S ‘,93g39 /I r��r Pm 332,409
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]
Unit Type of No. of
No Establishment Bedrooms
SUBDIVISION:
ACRES [Sgft /43560]
1,240 , %(Q s-k -' 2 rs
/ci n
[ ] Garbage Grinders /Disposals
[ ] Ultra -low Vol re Flush Toilets
DATE OF �� .
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
PROPERTY WATER SUPPLY: [ ] PRIVATE [ tiPUBLIC
] RESIDENTIAL [ ] COMMERCIAL
Building # persons Business Activity
Area Sgft Served. For Commercial Onlv
[ ] Spas /Hot Tubs
[ ] Othep "(Vpecify)
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be IV_ I)/ °A� �vs Pin ( Stock Number: 5744 - 001 - 4015 -1)
PERMIT #
DATE PAID
FEE PAID
RECEIPT #
] Temporary /Experimental
TELEPHONE: tc.61 2 -G0403
DATE:
•
5/2O '74 0
$ //D'oe
2 1/
[ ] Floor /Equipment Dra&ncs
Page 1 of 3
I
I + -
-_
II
I
I
If
I I
— 1
I I
- _ J
I
•
■
II
■
■
m ill
■
-i
• I
■■
EMU
■ I
i I
•
( -
177■■
■
�
; E■
lli•
--
-
J
1•
J
-
•
I
}
.
I
••
I
ii
, _
r ■ 4 ir + I
■v"'
L� i 1 !
■
Ill
�
•
_
_.
JL
L
�I
1 1=_
�l
-
-_
I
1
III ■
f
JI
I 1
l
I,
•
■ ■
■ ■
�
1 -
(µ
1
_J
J
1`
' I.
-_
�
1-
I
i r
•
L
I
1- � _C-
- RI
JJ
1 I
L -
�-
� II
I_T
I 1
1
,
■
: MI
I
I
-
�
---�
I
I
- I
I
I
1 I
,
I'
1 I
_
1
f
f
til
I : -
■
I. _ I__
i
1
_
f l
i IJ
LI
I
I
I _
i
` -
Tf
1 -
, I i__
`tlj
-I-
l i
I
-r
1 1
- J _I -
-
■
J I
i .
--
L
- f
I_.JIJ.-
I I I__
I_I._
f
1
•
■
I I
1
Jfl,
11
n _.
1 I _
L-
1 I
.
_
-I
-
-
I -
_
L
- _
I 1 L
J.
•
I-
-L
I I
I
-
l
-
1 .
u
1 1
_
J_ J I _ .
I
_
I
_
I
�_
1
-
I
I. J
1
_ 1
-_
-I
11 I
I
L
-
j)
._ _
1. 1 1
J
1 I ._ _
1
J_
1
I
-
_
•
-
I_
I
1
1
1 1)
1 _ 1
L_
1-
J-
I J
F
I L �
■_
- -
,,
1-
i
I 1-
'
1
I .__
71
1
L
L -
I�
J
IJ
1
1
I
1
1 I
L-I__
1 _
I ! L
I
!
■
1 1
1 I.
n :?
I f J I
L -
• -_
4
-I
-I_ -J
- -t
-
-
-
1
( - I
J
I I r •
I
i
I
-I
I
I
# I
;
[r
L I
H I
;
1
J
�
L_
1,
��
1 1
1_ h1
1
- 11
- �!
II
I
I
..ill
r
• F
1 r
t
1
L
�—
J , �_J
-
P
- I
r
1 1 I
1
,
_.
I- LLI I I
I 1
I f
I_
I I
1 L U_ __1
_
1-
i i -- l - L
.
.
1
'
II _
1,
- 1
--
1 JJ
4
1
_i_J
1 _ 1
ii _ -1 I I
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number / -� ° qa°
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes 8040
Site Plan submitted-by:
By
Plan Approved Not Approved D
HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4015-6)
SIGNATURE
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
TITL
County Public Unit
Page 2 of 3
PROPERTY ID #:
SOIL PROFILE INFORMATION SITE 1
SITE EVALUATED BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
l or,le_il /io
LOT: 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: 4o
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 PROPOSED SYSTEM TO THE FOLLOWING FEATURE
SURFACE WATER:40 FT DITCHES /SWALES: /66a a FT . I RMALLY WET? [ ] YES [of NO
WELLS: PUBLIC: A' /A FT � LIMITED USE: FT PRIVATE: ,� POTABLE WATER FT FT
BUILDING FOUNDATIONS: FT PROPER Y LINES: `
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOODING? [ ] YES [ NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH
REMARKS /ADDITIONAL CRITERIA: T/
HRS-H Form 4015, Mar 92 (Obsoletes previous editions which may not be us,d)
(Stock Number: 5744- 003-4015 -1)
AGENT: N' n( i
93
PERMIT #
SOIL PROFILE INFORMATION SITE 2
[Section /Township /Range /Parcel No. or Tax ID Number]
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: 46 SQFT
Munsell ; Color xtur
USDA SOIL SERIES:
Depth
/',tO /a-'
4epOlikr -
r•m•■ d �P f-zyto
to
to
to
to
to
OBSERVED WATER TABLE: INC S [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATE E ELEVATI : INCHES [ ABOVE /BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES ] NO MOTTLING: [ ] YES [ NO DEPTH: INCHES
BED [ ] OTHER (SPECIFY)
DEPTH OF EXCAVATION: INCHES
DATE:--
Page 3 of 3