DRAINFIELDBUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building
MIAMI SHORES VILLAGE, FLORIDA
PERMIT
Architect
Contractor
or Builder
Legal Lot
Description
N° 7376
DATE 19
Contractor's
License No.
Work to be performed under this Permit
B1
Subdi-
vision
Address of Value of II Amount of
Building Project S 11 Permit $
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the applica-
tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes respon-
sibility for work done by his agents, servants or employees.
Signed: INSPECTOR
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 prayer authorities of Miami Shores Village. In as
cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
CONTRACTOR OR BUILDER BY AUTHORITY
ABEnT y ad-
Date 8/22/94
Legal Description
Owner's Address
Date:
APPROVED:
Zoning
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 130 NE 97 STREET
Owner / Lessee / Tenant ZALESKI Master Permit 4����
Contracting Co. NORTH DADE SEPTIC TANK Address 800 NW 111 STREET
130 NE 97 STREET, MIAMI SHORES 33138
Qualifier DENNIS NEVILLE SS# Phone 751 -7676
State # 025836 -8 Municipal # Competency # 12842 Ins.Co. TRAVELERS
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION INSTALL DRAINFIELD
Square Ft. 200 Estimated Cost(value) $ 1000.00
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 work stated.
of own
Signature s d or Condo President
g /
Notary to Owner R / 9 _ ; ondo President
aci
My Comm is °F i� / �s •t; _
g •.•L•.•‘
iG J. * i. A i. * * J. M1 i. ii * .f * if ii **
FEES: PERMIT 36, RADON C.C.F. !. " NOTARY TOTAL DUE f
Buildin
Mechanical Plumbin
Tax Folio
Si f Con ractor o Owner- Builder
Date.
Phone 754 -8564
Nota y :1 to Con •r Owner - Builder
My Co o' i s s j N1 A•r& n T- 1,,. , -T
CANOED 11011
ra or
Fire Other
Electrical
I ngineering
CONSTRUCTION PERMIT FOR:
[- '], New System L'' Existing System [,1 Holding Tank [ � Temporary /Experimental
[/'-') Repair [' "] Abandonment (" Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
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 [ ; g — / ] [GALLONS / 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 � ' " /' / SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED
I CONFIGURATION: [ ] TRENCH [ % BED
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
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:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
AGENT: , /'
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 #
] MOUND [ ]
[ ]
EXPIRATION DATE:
CPHU
Page 1 of 2
INSTIIUc1 NS:
2E117:11 :3 : :.;. Permit:r clunr r_mber assignee by
/422L_C /- :. _ awe:: typo cf peum!'„ if 'Other" pec'fN typo in b`_on{r.
APPS :CAT ' : Props ty owner's ful: name.
E✓pr ^Z',_. Telephone number for applicant or c; n4.
AGENT: :.'raperty awn_.., Iegzily :mhf_ 2e_
MALLINC ADDRESS: I ?.O. Um: or etree nriling r dares *s for applicant Or agent.
LOT, C^i. {, SUBDIVISION or
PIROP TI :'Y DC: 27 character id number for property. (CI ?::IU may require° property appraise. ID (/ or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
T.ANN: Minimum specifications from Chapter IOD-6, FAC.
DRAINFIELD: Minimum specifications from Chapter IOD -6, FAC.
OTHER: Other specifications, such as operating permit requirements, tow - volume fluss't toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by c regis'ered engineer must be sealed.
APPROVED BY: County Public Health Unit (CP-LU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPKU.
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.
APPLICATION FOR:
[ ] New System
[ ] Repair
APPLICANT:
AGENT:
MAILING ADDRESS:
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]
LOT:
PROPERTY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [;:.] RESIDENTIAL
Unit Type of No. of
No Establishment Bedrooms
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 10D -6, FAC
BLOCK:
[ 1 Existing System (..,;] Holding Tank
[ ;,] Abandonment [ ] Other(Specify)
SUBDIVISION:
ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [. :] PUBLIC
[ ] Garbage Grinders /Disposals [„ ] Spas /Hot Tubs [. Floor /Equipment Drains
[ ] Ultra -low Volume Flush Toilets [ .. ] Other (Specify)
j /;
APPLICANT'S SIGNATURE: - ,;,,;
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
[
] COMMERCIAL
Building # Persons
Area Soft Served
TELEPHONE:
I
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
DATE:
] Temporary /Experimental
Business Activity
For Commercial Only
HRS -H Form 4015 Mar 92 (Obsoletes revious editions which may not be used
P Y 2 ° � � � � �' ��" `- Page 1 of 3
(Stock Number: 5744 - 001 - 4015-1) ..
:
•
•
';\11;,"
..
l
LOT:
PROPERTY ID #:
BLOCK: SUBDIVISION:
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ]
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
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
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
HRS-H Form 4015, Mar 92 (Obsoletes previous editions 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.
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
YES [ ] NO NET USABLE 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 FEATURES:
SURFACE WATER: FT DITCHES /SWALES: FT NORMALLY WET? [ ] YES [ ] NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: FT NON - POTABLE: FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: - FT POTABLE WATER LINES: FT
10 YEAR FLOODING? [ ] YES [ ] NO
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES ['] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / 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: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [.',] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:
Page 3 of 3
, .n
•' L -
J'- rl
Notes:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION, PERMIT
i
Permit Application Number
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744-002-4015-6)
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
•
Site Plan submitted by i
SIGNATURE TITLE
Plan Approved Not Approved Date
B County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Page 2 of 3