638 NE 97 St (5)STATE OF FLORIDA- DEPARTMENT OF HEALTH AND REHAB:I :LITATIVI: Sl':RVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM - CONSTRUCTION PERMIT
Building Permit: #: 942,-.4
Application/Permit Number:_
Authority: Chapter 381, F.S.
& Chapter 10D -6, F.A.C.
Application Is For: New System [ ] Repair [ ] Date Application Received: —_
Existing System [ ] Experimental System [ ]
(Temporary) [ ] Tank Abandonment [ ] Amount F'a.i_d:$_
Holding Tank [ ] Other (Specify):
NOTE: PERMITS EXPIRE ONE YEAR FROM DATE OF ISSUANCE AND ARE N0 ' RENEWABLE. RF:iIU 1.= kM
AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM DATE OF ISSUANCE. APPROVAL OE A :;'{S'] . M OE
NOT GUARANTEE SATISFACTORY PERFORMANCE FOR A SPECIFIC PERIOD 0E TIME.
TO BE COMPLETED BY APPLICANT:
Owner: A 414k /r.S Telephone: (Work) (Home)
Owner's Mailing Address: `J( 17 .rT
Owner's Agent: ./:.: lA.1r Sa Jima. Telephone (W) S1 (H) _
Agent's Mailing Address: /We) A140. J / flJ. aye City: /940661e State: Zi :
Property Street Address: 6-!? die 9 7 ST /9/4/'1/ Si/o .
Exact Directions to Property:
Lot # Block # Subdivision Unit Date Subdivided
Section: Township: Range: Parcel #: Zoning Designation:
Property Size: Square Feet /Acres
Water Supply: Private [ ] Public [ ] Limited Use [ ]
Is Sanitary Sewer Available: Yes [ ] No [ ] If No, approximate the distance to the ev,
line closest to your property:
Is Public Water Available: Yes [ ) No [ ] If No, approximate the distance Lo the •at
line closest to your. property:
Applicant'S Signature:
BUILDING INFORMATION
Receipt #:_.
City: A4 S, State: _ , 41 L.
Type of
Establishment # of Units Building # of Persons tl of Seat:: ilou s
Commercial, esidentia) Area (sq Et)
(circle one) & # of Bedrooms
Date:
Cpe , t i
Plumbing Fixtures: Garbage Grinders /Disposals _ Spas /Hot Tubs r Floor/Equip. Drc..n::a
Ultra -low Volume Flush Toilets Other
BUILDING PLANS MUST BE ATTACHED SHOWING OFFICES, BEDROOMS, TOTAI:.. BUILD:I:NG AREA, AND
PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, F.A.C. IN ADDITION, A DETAILED SITE FLA( A 1
SURVEY, DRAWN TO SCALE, MUST BE ATTACHED SHOWING PROPERTY DIMENSIONS, BUILDING LOCAT] !N
AND PERTINENT FEATURES REQUIRED TO BE SUBMITTED PER CHAPTER 10D -6.046 F.A.C.
DADE COUNTY DEPARTMENT OF PUBLIC HEALTH
RECEIVED OF
$ (fit) U C.)
Septic Tank Receipt
N° 22545
19 9
DOLLARS
LOCATION 6 3 3' C ST 100
FOR 9 .2_ �s -- °< -- c f / — ,8#
BY
This receipt not valid unless dated, filled in and siVed by authoriz employee of deparTment.
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