2000 DRAINFIELDDate
Qualifier
State #
Arc?iitect/Engirteer
o siing Company
Mortgagor
Sam Ft.
l•
ARMING TO WNE
PAYING TWICE F
CR AN ATTORNEY
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
'! Job Address / r ' `0 -C!' Tax Folio
Legal Description
Owner /Lessee / Tent t ; / GV
Owner's Address E S ,/.E .
Contracting Co. ( 4 • C ?T I6 Pig t d) -cat.J Sic
Historically Designated: Yes No
5;1,y1 E - eoc /ci„
Municipal # Competency #
Address
Address
Permit Type (cirre2e one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
W'1? DESCRIF•l'ION S
Estimated Cost (value) , , ®
•
YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY RESULT IN YOUR
R IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITII YOUR LENDER
EFORE 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
PLUMING, SIGNS, POOLS, ROOFING and MECHANICAL WORK.
AVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Notary as to Owner sand/or Cando President
My Commissionn xoi es:
:, F;otar STEPHEN E COCKING
Public
Stcto of Florida
n�� Cornet Fuca: O0 /04/01
•
Cornmfh CC6691 aD
FEES: PERMIT ,..6?)
APPROVED:
Zoning Building
Mechanical Plumbing
Address
Address
Notary as to Con
My Conlmissi
Master Permit #
Phone
- - 3. ;,' - 7eg C? •
Signature of Contractor or Owner- Builder
Electrical
?,.0 o /e7c
/q9
Ins. Co.
or or Owner -Buil
OFFICIAL NOTARY SEAL
S tAAROARITA tAONTIEL
0 comas -nos LUMBER
0079727
O n
,„V cw3lacS5SZON EX
OF FLOC EC. 17,200 2
RADON C.C.F. / ' NOTARY BOND
TOTAL DUE ..YZ •
ate
Date
�
Structural Engineer
CONSTRUCTION PERMIT FOR:
[ ) New System [ ] Existing System
[ J Repair [ ] Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
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. 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.
SYSTEM DESIGN AND SPECIFICATIONS
T [
A
N [
• [
D g J 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:
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
. STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS &
.51S Pr frl
BLOCK: SUBDIVISION:
] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI - CHAMBERED /IN SERIES:[
] [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 [ J PER 24 HRS NO. OF PUMPS: [ ]
J INCHES
DH 4016, 10/96 (Replaces HRS -H Form 4016 (page 1) which may be used)
(Stock Number: 5744- 001 - 4016 -0)
Chapter 10D -6, FAC
[ ] Holding Tank [ ] Temporary /Experimental
[ ] Other(Specify)
AGENT:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
j [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT) [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: ( ] INCHES
TITLE:
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
] MOUND ( ]
]
I VC
TITLE: CHD
EXPIRATION DATE:
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 i :horize -2presentat ve
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.
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.
Notes:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
> r
r
FIRS-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.
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Site Plan submitted by:
SIGNATURE TITLE
Plan Approved Not Approved Date
By County Public Unit
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Page 2 of 3