30 NE 96 St (11)MIAMI glORES VILLAGE, FLA.
JOB / % �
ADDRESS 96
INSPECTIONS s r/ p = - 7
TIME READY —
REMARKS:
N° 5759
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INSPECTOR tkA� DATE
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MIAMI SHORES VILLAGE, FLA.
JOB
ADDRESS JO /L (-� �
sL
INSPECTION 9� Ce= l / .s� W
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TIME READY r '�- — `�' - ry
REMARKS:
INSPECTOR u-' g(c
N° 5899
DATE 4 -4-
Notes,;_
Scale: Each block represents 5 feet and 1 inch = 50 feet
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Site Plan submitted by.
Plan Approved
By_
DH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stodc Number: 5744- 002 - 4015 -6)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER�� � � ��
Permit Application Number
PART II - SITE PLAN
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RaDVeWT/A-We LQOr (I. ePio, r e d 577,01
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Signature
Not Approved
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Title
Date -/ gb° 9
County Health Department
Page 2 of 3
BUILDING INFORMATION
1
A Po CI
2
3
4
APPLICANT'S SIGNATURE:
STATE OF FLORIDA PERMIT # Q7
DEPARTMENT OF HEALTH DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ 'l S. f)6
APPLICATION FOR CONSTRUCTION PERMIT RECEIPT #
Authority: Chapt r 381, FS & Chapter 10D -6, FAC
APPLICATION FOR:
[ M J New System [ Existing System [ Holding Tank [ Temporary /Experimental
[I] Repair [ G ] Abandonment (G -T Other(Specify)
APPLICANT F'E: ^ &9s
AGENT
:
MAILING ADDRESS: 800 � ! 1 � ` � frt to, m ( (4• ` 9 r
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: ..3)-y BLOCK: S UBDIVISION: A Mi ! ` %' SUBDIVISION. 8 -
PROPERTY ID # : 90{9-0/ -64 [Section /Township /Range /Parcel No.] ZONING:
PROPERTY SIZE: ® ACRES [Sqft /43560] PROPERTY WATER SUPPLY: ( j PRIVATE [ 1'] PUBLIC
0
PROPERTY STREET ADDRESS: 9)c) /h � J 1 G� 0.4 ; J (� 7`{ t `ores 0 s %1 9, 42_7 2 et
DIRECTIONS TO PROPERTY: r
Unit Type of No. of Building # Persons Business Activity
No Establishment Bedrooms Area Sgft Served For Commercial Only
[PA Garbage Grinders /Disposals
[A4 Ultra -low Volume Flush Toilets
DH 4015, 10/96 (Replaces HRS -H Form 4015 e 1] which may be used)
(Stock Number: 5744 - 001 - 4015 -1)
0 eel ,..i' r le Fro 'ro o
[C%] RESIDENTIAL [ ] COMMERCIAL
TELEPHONE :304-z - 7s - 7 76 7
[W] Spas /Hot Tubs [ Pte]' Floor /Equipment Drains
(4 Other (Specify)
DATE: 3
Page 1 of 3
• t),-,),) of peii:, "t:thet:" rtp‘.eify
full main.
nut fU enplicr.nt OT c;:ra.
cm.hm t
NC A. .• city, ttp:te onti cpplicer:. tot• :‘:Jort.t.
fut. (tecortlecl c:.• le 112 lot in :n of the lot
cl.:: c: r::•.ett bo ttitcchas.l.
J. • : u vJr ccti CC:A.:1y "'• •
Cr ••
; m:bibt:i I 1 pollert> Ilppraker I!: • ■ri ) eel Mit/tort311 't;,r number.)
oy (.3,60 ?nye: ::tond
.• • pt•'.1.i.: • t;t:ecnt.:, , c• :::7•ter
• , .flc• nr.?mv,),S. ,:ond •It;):7'.
....l • •
:ru lot)) without n tct eddrs, t.;:'et
t • ' , to lot zu ,l•on.yin.8 of luection.
•: • .'..,;N:
tylp,) u :Ii :,:•,:r1:It :1 7;0'01:: F.3, Clt:•2:,...•• 7.0
room:: ••n:;.; ex p ee t..-,6 to :o:1'Iy for
hnbitr.b1:: c nit, exch ct:• : c or fully
pdtim, to) . .:tte:od en out cu fot: ezch
;') Ntnt:'.).‘•, of or c Fc's eisMlir").r. 2. pc:
1.'CW •.•tIone only. chirt:), 0:' irZO:":1 :::! by
• C.:•1•r•oltt
11:1,:11 I:7min: With 11:!Illi1,27' lnstallttc; 0; "NA" if not epplic:t.)Io.
i.111 ot• applieptitm nn CIO Ntihmitted to t nonropt•i:th: fees oml
to rhowin3 cl;: ler • t'ry):: of m••••L'scri‘t: t: • :mildin! so.:./11••ilnti • t
on :+yucin com2oner:: tiO. tltmc of
:.:),:••s, oh: :::1.)etetl. C: ;711': :,../JCZtiOnCC oo 0 :1A.PiT:7; oo 0 nM!
r.t.n• 1»tnom fz:cilitin:: fe7.)turor, on cii fez:tut:et: )..vlt."-. '75 c)`: 1: ony
ellt:).i't 2CD f..:ot of lot.
';':".1i:•1C, SICO!1:1!0.11 (testtlonees) of bedramell 0A7Cr" !Wit.
e:.1......!)1 0 4 .: 1 .ot):•p! the of the eltr.bFrlly-Y ^it type: , other
nc...ccss::-y to C:0 cornpot,ition nntl cl2001ity of wnstevirter.
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date - Mb 9Job Address 31 NL 94 /W ' 47,- • Tax Folio /1- 3e:1 (o ' 0 /3 - t 2
Legal Description
Owner/Lessee / Tenant -- ‘N4 9 E L e � � P (7"'
Owner's Address 30 Ala Q`{ 7;41
Contracting Co. L L OYD -A /2 %' .DtVE
Qualifier SS# Phone 305 •7,5 /- 76 - 7Cn
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 /AJ 7/? G 3t,b LUc 7 R7O`/L!�
Square Ft. Y Ic OR I1-/L ootz--, :yme Estimated Cost (value) S$ /(1e0 • co
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.
J 644444:1, , Walt
Sign of owner and/or Condo President Date
,g / • ,r_ iI
Date
Notary to Owner
My Commission Expires:
LESI'1RE C .,.... '
My Comm Exp
Bonded By Service Ins
No. CC649326
I 1 Personally Known 1 1 (Noes
FEES: PERMITT3 S RADON
APPROVED:
Zoning Building
Mechanical Plumbing
3- /6 -99
3
Historically Designated: Yes
T!G
Address
Notary as to Contra or or Iwn urlder Date
My Commission Expires:
LESTER E. CROCKETT
My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
1 Personally Known 1 1 Other I D
C.C.F. 1 • d, O NOTARY
Electrical
No
Master Permit # `. q3
Phone 3613 73
it AJiJ
BOND 3 0.0
Z
TOTAL DUE 3 SC -
0
Engineering
CONSTRUCTION PERMIT FOR:
[; ] New System ['J/Existing System (/ ], Holding Tank [ 1 ] Temporary /Experimental
r '] Repair [] Abandonment [11 Other(Specify)
APPLICANT:
PROPERTY STREET ADDRESS: )
•
• ' v'L.
LOT:
PROPERTY ID #: /
T (
A [
N [
K [
AGENT: L I
iii rv� ..-� �" � �'��• � u''i Ca e7 -�� y�de, �"`�� �_�.� °��C'
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK: SUBDIVISION:
] AGALLON,S''
] (GALLONS
] GALLONS
] GALLONS
SYSTEM DESIGN AND SPECIFICATIONS
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.
/ GPDl_,SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
/ GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
PER DOSE DOSING TANK CAPACITY DOSE•RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
r, ' SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ -] STANDARD [ ] FILLED
CONFIGURATION: [ ] TRENCH [ C.4-
FILL REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
INCHES
DH 4016, 10 /96 (Replaces HRS -H Form 4016 (page 11 which may be used)
(Stock Number: 5744- 001- 4016 -0)
e . a c _, � [ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
D
R
A [ ] MOUND [ ]
I ( ]
N
7
F LOCATION OF BENCHMARK Gri A=4 ! � ✓ti f' _ � ` .J e' G% v' �
I ELEVATION OF PROPOSED SYSTEM SITE [ %' `�- ] {INCHE,SJFT] [ ABOVF/ BELO %t4p4ENCHMARE./-I(EFERENCE POINT
L BOTTOM OF DRAINFIELD TO BE [ 44 ([INCHES /FT] [ABOVE/BELOW) BENCHMARK/1(EFERENCE POINT
D
0
T
H
E
R
EXCAVATION REQUIRED: [ 3C-1 INCHES
TITLE:
TITLE:
PERMIT ,,'
DATE PAID �� ° `✓
FEE PAID $ •""/
RECEIPT 1 i
CHD
EXPIRATION DATE: / f r
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 10D -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.
4
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.