139 NE 96 St (7)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date Job Address / 3 9 ft c) & S / Tax Folio
Legal Description Historically Designated: Yes No
Owner /lessee / Tenant J i C44. /tai C 4v GI j,� 'n� & d c 0 e� Master Permit # � � 3
Owner's / � r 3 7 A g, i� C Phone -k 3 v S. `) 5/ . '7 .5 f 7
Contracting Co. o. el )/ --14., Of eto %Gw
Qualifier ...�'l 6."J C • a.,'' ss# __ Phone �‘). C. /''' 7 rn
State # Mmiigpal # 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 / 6' y/ e� ���1 , P /c� -
r
Square Ft. adv
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 ie EFORE RECORDING YOUR NOTICE OF COMMENCEMENT.)
as to
iy Commission
FEES: PERMIT
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 perforated to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required for ELECTRICAL
?LUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
OWNERS 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.
iiultofiCart
4�F� �I
7d1T1Ie 1 �! ?,� ,� � A f rtw' C)? n e.(5.
1R9� „� L f C 7`,41. }3
/.. , EXP. •NiAt 3
�J�.,e�e'JS J.
APPROVED:
Zoning Building
Mechanical Plumbing
to
to
Address / 9 f3 a / 0
Estimated Cost (value) /c
gnature of Contractor or Owner - Builder
Notary as to Contractor or Owner - Builder
My Commission Expires:
RADON C.C.F. l ' . NOTARY _ BOND 3
Electrical
Date
Date
TOTAL DUE 3.70
Structural Engineer
CONSTRUCTION PERMIT FOR:
[ ] New System [ ) Existing System
[, ] Repair ( Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
PROPERTY ID #:
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH , DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $
CONSTRUCTION PERMIT iii RECEIPT #
Chapter 100 -6, FAC
Authority: Chapter 381, FS &
BLOCK: SUBDIVISION:
SYSTEM DESIGN AND SPECIFICATIONS
T [
A [
N [ ]
K [
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DH 4018, 10/98 (Replaces HRS -H Form 4018 (page l)xtdartl fti$y.b* uset0
(Stock Number: 5744- 001- 4016 -0)
[� \) Holding Tank [`,] Temporary /Experimental
[ \ y Other(Specify)
AGENT:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[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. DEPARTMENT OF HEALTH 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.
[GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[
[GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:( 1
GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS)
GALLONS PER DOSE DOSING TANK CAPACITY DOSE MATE [ ] PER 24 HRS NO. OF PUMPS: (
D [ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE ( �-_ J (I
L
D FILL REQUIRED: [, ) INCHES EXCAVATION REQUIRED:
SYSTEM
[ - 1 STANDARD [ ] FILLED
] TRENCH [ ) BED
] [INCH S /FTJ [ABOVE/BEL_ W BENCHMARK/REFERENCE POINT
f Zit
TITLE:
TITLE:
MOUND
/FT] [ABOVE/ = ,� - BENCHMARK /REFERENCE POINT
INCHES
a
EXPIRATION DATE:
1,
? 5 o-w r"9
CHD
Applicant
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICATION FOR: Check type of permit; if "Other" specify type in blank.
APPLICANT: Property owner's full name.
TELEPHONE: Telephone number for applicant or agent.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID #: 27 character ID number for property. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter I0D -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -6, FAC.
OTHER: Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
Scale: Each block represents 10 feet and 1 inch = 40 feet.
Notes:
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744-002 -4015 -6)
PART II - SITEPLAN
Not Approved
Site Plan submitted by:
Plan Approved
By County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Date
Page 2 of 4