DRAINFIELD•
Date
Legal Description
Lessee
Owner's Address
Contracting Co
WORK DESCRIPTION
Square Ft. 20 0
ysatiav
Notary as to Owner and
My Commission Expires:
3/ /9
APPROVED:
Zoning
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Job Address 07 44 1iJ 9 / Tax Folio
/ Tenant,;
dd,? ,D/ ld) S i' L Address ,5 /D �.L.t) /.fef '
Qualifier 0,4 L 61/ Z.sDtt-) Phone Z27- /6
State # 09,7 Municipal # Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRIC CHANICAL ROOFING PAVING PENCE SIGN
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 a d zoning. Furthermore, I
authorij- the above -named contractor to do the work stated
A(/ rt
gnatur of owner and /or Condo President
Date:
e o RY SEAL
O BARBARA T
� COMMISSION NUMBER
CC360191
** * * * i 9r Mt COMMI SIGN
glAR ,1998
FEES: PERMIT RADON C.C.F.
Fire Other
Buildin
Mechanical Plumbin
���
Estimated Cost ( value ) � sc�
Date:
Signature of Contractor or Owner - Builder
otar /as to Cont
My Commission Exp
NOTARY 5 TOTAL DUE
Master Permit # %),A)
Phone
Y s A.
..actotstiM6N
MfieiviNilder
COMMI ION MO. OF OA
MY COMMISSION EXP. FEB. 7,IS97
* **
Electrical
Engineering
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[ ] Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
BLOCK: SUBDIVISION:
SYSTEM DESIGN AND SPECIFICATIONS
T [
A [
N [
K [
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION: [ ] TRENCH
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUIRED: [
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
[ ] STANDARD
] INCHES
AGENT:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Nuiber: 5744-001- 4016
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -6, FAC
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER ?ERMITS
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISF %CTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICH SERVED Ai 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.
J [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SER: :ES:j ]
] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SER :ES:[ ]
] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
SYSTEM
[ ] FILLED [ ] MOUND [
[ ] BED [ [
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE PO::NT
] [INCHES /FTJ [ABOVE /BELOW] BENCHMARK /REFERENCE PO::NT
EXCAVATION REQUIRED: [ ] INCHES
]
TITLE: CPHU
EXPIRATION DATE:
Page 1 of 2
?e -m_ :.a caia ._.._. = t a €ipac.:
:CI:: _..- , i' `u_T__ i pee icy type in b :r ^S.
t 3.irz rt J_ rgcnt.
YAIL' F: ?:.'.. S: _. . a; ,..... er :, :..._ .' r - • :.-_ r,:_., =a_ cppiicart c: agent.
1.07, LIICIa, SU3DIVISION a:
charecte: it rurbce for property. (CIKIIJ nacy require property cir S (] (1: fwc4for.Itova: `1 /_1.nre /pcsce! number)
SYSTEM DESIGN AND
5 ? c : :':cAh
ioeinimum spceificctioas from Ceicpter IOD -is, !PAC.
`.D:?A!: N IELD: Minimum specifications from Chapter IO -5, IFAC.
Oz L Ea: Other specifectiu s, such cs opercting permit requirements, uirements, tow- volume fart toiiets, vcricnce Q:ovicas.
SPECIFICATIONS 3Y: Name of Individual providing specifications. If resigned by c registered engineer :rust bL cede.,'..
APR ROVED 31!: County ?ublic Hecith Unit (CPHU) personnel reviewing mid cpp:vving permit.
DATE :SSUED: :?etc permit is issued by CPHU.
(EXPIRATION DATE: One yecr from date issued if the system hcs not been installed. ?ermts for system repairs become void v3 drys from the date
issued.
s
CONSTRUCTION PERMIT
[ ] New System [ ] Existing System -
V ] Repair [ ] Abandonment
''', _ (.
l c r L
APPLICANT:
PROPERTY STREET ADDRESS: 2 J- ()
LOT:
PROPERTY ID #:
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -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
. f ] /1
T [ ( '.- �/t ] [GALLONS / GPD]
[GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:( ]
A
! f •`�� 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: [ ]
0 D ( J 1 SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [ 1
BED [ ]
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE ( ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINr.
E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN:
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY: (
STATE OF FLORIDA PERMIT # ? 4T 1 ` b
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID 4 - 2. �=
ONSITE SEWAGE DISPOSAL SYSTEM - - RazD $
CONSTRUCTION PERMIT RECEIPT # R
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
BLOCK: SUBDIVISION:
DATE ISSUED: 4
BETTER BUSINESS FORME 1201808
Tallahassee. FL— (904) 878 -5401
A
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 - 0)
] Holding Tank [ ] Temporary /Experimental
] Other(Specify)
AGENT: /..6
4 t
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
TITLE:
TITLE:
i (: CPH
EXPIRATION DATE:7_ 9
d
Page 1 of
Scale: Each block represents 5 feet and inct3= 50 feat.
I.- - t
i 1 }
Notes
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
. APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUC
-
Permit Application Nrfrn
PART II - SITE PLAN
t r'
t .
rr ∎ r-1-
}1 t
--� r - J'
fi r; -
Ti •
•
}
T 1
Site Plan submitted by
- r -' - . �
f 1- ' r t I y — —
— — - - • - } - 1-
-1- r
SIGNATURE
7 -
. — _ - --
- - r r-
•
} T I —t *- }
rte I
'
-t
-T'i --
1' --r-
1 ' II - t t .- � -�I-'-
1.4 ., , ` t - t 1
I
I-- i { 1 ,1-1 1 (!-f 4 k 1-1-,-
1,1 i t 1 1 L-_-__
Plan Approved r Not Approved
By ( .2,12—k___-- r 1A-{,1"
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
+I
RStorfft 15. Feb 85 (Obsoletes previous editions which may not be used)
(Stock Numb *5744- 002.4015.6) -
TITLE
//` .
Date L/ ='
County Public Unit
Page 2 of 3
AGENT:
1
2
3
4
APPLICATION FOR:
[ ],New System
[ , Repair
APPLICANT:
--, AscrmENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
[ ] Existing System [ ]
Holding Tank [ ] Temporary /Experimental
[ ] Abandonment [ ] Other(Specify)
Ai-% S
MAILING ADDRESS: //
«
�.�/ ` //
TO BE COMPLETED BY APPLICANT OR APPLICANT'S SREQUIRED AUTHORIZED ADMINISTRATIVE CODE �
SE
SITE PLAN SHOWING PERTINENT FEATURES
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
DATE OF
BLOCK: SUBDIVISION: SUBDIVISION:
[Section /Township /Range /Parcel No.] ZONING:
LOT:
PROPERTY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
APPLICANT'S SIGNATURE:
ACRES [Sgft /43560]
] Garbage Grinders /Disposals /
] Ultra -low Volume Flush To].
[ ] RESIDENTIAL
No. of
Bedrooms
( ! •/ j / / j
!�✓ / /!'
Y
HRS-H Form 4015, Mar 92 (Obsoletes previous editions
(Stock Number: 5744- 001 - 4015 -1)
PROPERTY WATER SUPPLY:
Building
Area Saft
[ ] COMMERCIAL
C
which may not be used)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
TELEPHONE: !
[
/-
DATE:
OOP
] PRIVATE [ -J- PUBLIC
# Persons Business Activity
Served For Commercial Only
] Spas /Hot Tubs [ ] Floor /Equipment Drains
] Other (Specify)
Page 1 of
APPLICANT:
LOT:
PROPERTY ID #:
BUILDING FOUNDATIONS:
of FLORIDA
1 DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK:
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 PLF,$: (. ]
TOTAL ESTIMATED SEWAGE FLOW:
THE MINIMUM SETBACK WHICH
SURFACE WATER: -- FT
WELLS: PUBLIC: --- FT
SUBDIVISION:
[Section /Township /Range /Parcel No. or Tax ID Number]
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE: ._'
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
CAN BE MAINTAINED FROM THE
DITCHES /SWALES:
LIMITED USE: FT
FT PROPERTY LINES:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ JNO
10 YEAR FLOOD ELEVATION FOR SITE: c FT MSL /NGVD
Munsell # /Color Texture
USDA SOIL SERIES:
Depth
to
to
to
to
to
to
to
to
to
SITE EVALUATED BY: /,.././ //j
c -
HRS Form 4015, Mar 92 (Obsoletes previousditions which may not be used)
(Stock Number: 5744- 003-4015 -1)
AGENT: f
YES („] - NET USABLE AREA AVAILABLE: ACRE:
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500,GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: "7 SQF:
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN'
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
FT NORMALLY WET? [ ] YES [
PRIVATE: FT NON- POTABLE: F
FT POTABLE WATER LINES: F
10 YEAR FLOODING? L ] YES [ ]'N
SITE ELEVATION: ' 1 FT MSL /NGV:
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
Munsell # /Color
USDA SOIL SERIES:
PERMIT #
Texture
�
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 (4_NO MOTTLING: [ ] YES [ DEPTH: INCHE
/ i
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: /
DRAINFIELD CONFIGURATION: [ ] TRENCH [ 4-BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DEPTH OF EXCAVATION: / INCHE
DATE: L . • ; �f
Page 3 of