DRAINFIELDPERMIT APPLICATION FOR MIAMI SHORES VILLAGE
a
Date 9/19/94 Job Address 131 NE 97 STREET Tax Folio
Legal Description
AITKIN- HERNANDEZ
Owner / Lessee / Tenant Master Permit #
Owner's Address 131 NE 97 STREET, MIAMI SHORES 33138 Phone 756 -5100
Contracting Co NORTH DADE SEPTIC TANK Address 800 NW 111 STREET
Qualifier DENNIS NEVILLE
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. 300 Estimated Cost(value) $1100.00
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
be done in compliance with all applicable laws regulating constru
al.rize the above -named con actor o do the w ork stated.
AAAC. /ICU
Signat
Date:
gature of owner
Daye :
Not4was to Ow
My Creission Ex
APPROVED:
Zoning
Mechanical
and /or Con
SS#
Phone 754 -3375
1
ContratiO or Owner-Builder
or or Owner-Builder
MY COMM1531o31 EXF■RES
EOttDED THRLI twwiCxLEEMY 3 A1;fiZfATF3.3
* * * * * * **
NOTARY TOTAL DUE �'
Other
Electrical
%ngineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ! Existing System [ G'j Holding Tank
[ 1 Repair [ /�]'" Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
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PROPERTY ID #:
./] SQUARE
[ 1 SQUARE
TYPE SYSTEM:
CONFIGURATION:
FILL REQUIRED: [
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
FEET
FEET
[
[
]
] INCHES
BLOCK: SUBDIVISION:
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
PRIMARY DRAINFIELD SYSTEM
SYSTEM
STANDARD [ ] FILLED
TRENCH
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 #
[. /] Other(Specify)
AGENT:
TITLE:
[ ] MOUND [
EXCAVATION REQUIRED: [ ] INCHES
Temporary /Experimental
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
EXPIRATION DATE:.
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
[1//v ] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI - CHAMBERED /IN SERIES :y 1
[ 1 [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: [ 1
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
TITLE: CPHU
Page 1 of 2
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Pcrmit trycltin5 ...urnhc::Essinaccr. ‘N,
APFII.ICATA1 70:: Ciwe It type of perin:t, iipecify typc in blEnc..
APCAN: :?roperty own fur/ nun.e.
Telephone numb For applicant a: Egent.
ACEN7. PropErty iegr.1;y
MAILIN. AZ:DRESS: P.O. bon or rtree: mi1in d for applicant or rl,seni.
LO1', 131.0C[(, SUBD/VISION or
PRCPERTY IDC: Ti character id number fr,•:: p:aperty. (C?:-IU may sequin: property dcc D c Eic:loritotinf tzcnse/E, czfee! number)
SYSTEIC., DEsION AND
SPECIFICATIONS:
TANA: Minimum specifications from Chapter 10D-6, PAC.
DRAKNFIELD: Minimum specifications front Chapter 10D-6, PAC.
OTHER: Other specifications, such Es operming permit requirements, Mw-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 (CPH7J) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPU.
EXPIRA,TION DATE: One year from date issued if the system has no been installed. Permits for system repairs become void 90 days from the date
issued.
1'
APPLICANT: AGENT:
LOT: BLOCK: SUBDIVISION:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
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:
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 FEATURES:
SURFACE WATER:
WELLS: PUBLIC:
BUILDING FOUNDATIONS:
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 1
Munsell # /Color Texture Depth
to
to
to
to
to
to
to
to
to
USDA SOIL SERIES:
FT DITCHES /SWALES: FT NORMALLY WET? [ ] YES [ ] NO
FT LIMITED USE: FT PRIVATE: FT NON - POTABLE: FT
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
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH [..,.] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
SITE EVALUATED BY:
FT PROPERTY LINES: FT POTABLE WATER LINES: FT
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1)
PERMIT #
[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: SQFT
10 YEAR FLOODING? [ ] YES [.] NO
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
USDA SOIL SERIES:
to
to
to
to
to
to
to
t _
to
DEPTH OF EXCAVATION: INCHES
DATE:
Page 3 of 3
.. L ...a. P., .. _ ON: ':!:C. a.6. :a .. °i ?O'. _
.�
•
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Scale: Each b ock represents 5 feet and 1 inch = 50 feet.
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744- 002 - 4015-6)
PART II - SITE PLAN
Permit Application Number
Notes:
Site Plan submitted by: SIGNATURE TITLE
Plan Approved Not Approved Date
County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC TEAL H UNIT
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