567 NE 96 St (11)Data
Type Insp'n
Permit No.
Name
Address ^
Approved
Correction
Re- Insp'n Fee
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Compan
Phone #
For Inspector: t 1 ((�f Ge),
V \
(� Time
c_1(
C41-i
A d A
ix�
Approve (J
Date Time
Type Insp'n An,/
Permit No.
Name�f�.
Address U/ 7 7 61
Com p an y'���
Re- Insp'n Fee
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Building Inspection Request
Phone #
For Inspector: , - / P e & % "ate
Correction ❑
Page 2
IMPORTANT NOTICES
1. DO NOT BEGIN ANY WORK WITHOUT HAVING RECEIVED YOUR VALIDATED PERMIT AND PERMIT CARD. Applying for a permit does not grant
the right to begin construction. HOURS OF CONSTRUCTION are limited to: Monday through Friday from 7:30 a.m. to 6:00 p.m., and Saturday from 8:00 a.m.
to 5:00 p.m. No inspections will be conducted on weekends or holidays.
2. All construction of demolition areas MUST BE MAINTAINED IN A CLEAN, NEAT AND SANITARY CONDITION free from construction debris.
3. STREETS AND NEIGHBORING PROPERTIES SHALL BE KEPT FREE FROM DIRT AND DEBRIS.
4. SWALES MUST BE PROTECTED FROM BEING DAMAGED BY EQUIPMENT OR VEHICLES, AND MAY NOT BE USED FOR STORAGE. A bond is
required for work in or near the street/sidewalk.
5. CONSTRUCTION TRAILERS ARE PROHIBITED ON SINGLE FAMILY RESIDENTIAL CONSTRUCTION SITES. Other construction may have a trailer
which requires a separate permit.
6. PORTABLE TOILETS for a construction site require a separate permit.
7. DO NOT DISCHARGE WATER INTO THE RIGHT OF WAY OR STORM DRAINS without approval from the Building, Planning and Zoning Department.
8. EQUIPMENT AND MATERIALS SHALL BE STORED at least 10 feet from the edge of pavement.
9. Department of Health and Rehabilitative Services (HRS) approval is required for applications involving septic tanks. Department of Environmental Resources
Management (DERM) and/or Miami -Dade Water and Sewer Department (MDWASD) approval is required for applications involving sewers.
AI'FIDAVI;T - Please read carefully.
Application is hereby made to obtain a permit to do work and installation as indicated. I, the OWNER of the property, 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, POOL, EXTERIOR DOOR, MECHANICAL, WINDOW, FENCE, DRIVEWAY,
ROOFING and SIGNS and there may be additional permits required from other govemmental agencies.
I, the OWNER of the property, have disclosed all information related to any work at the property performed in the prior twelve
months to the Building Official. Further, I am fully aware that if the cumulative cost of work to my home or business under this and
any other permit equals or exceeds fifty percent (50 %) of the fair market value of the structure, the entire structure must meet the
present federal flood criteria for finished floor elevation. I am also fully aware that if the total cost of work to my home or business
under this and any other permit exceeds fifty percent (50 %) of the replacement cost of the structure, then the entire structure must
conform to the current code requirements of the Building Code.
WARNING TO OWNER: Your failure to record a NOTICE OF COMMENCEMENT may result in you paying twice for
improvements to your property. If you are spending more than $2,500 or intend to obtain financing, you may wish to consult with
your attorney or lender before recording your Notice of Commencement. The Notice of Commencement must be recorded at:
22 N.W. 1st Street, P' Floor, (305) 679 -1078. Once recorded, the Notice of Commencement must be POSTED AT THE JOB SITE in
accordance with Section 713 -35 of Florida Statutes. Review the brochure at Village Hall on Construction Lien Law and
Choosing a Contractor.
STATE OF FLORID ) COUNTY OF MIAMI -DADE
S gna�f Owner
Print Name
Sworn to and subscribed before me this day of
RID
PERMIT APPLICATION
ature of Contract.r - ua fter
Lc 7l; G ackO=T
IAMI -DADS
.) Print Name 9 S subscribed before me thi2 Y. day of C--k'
Signature of Notary Public - State of Florida Si . ure of No .. Public - tate o Fl.rida
SEAL: SEAL: a�, P
l 1F' U 6 b1NCLLII :1•
O
Personally known OR, Produced Identification Personally known OR, Produced Identification
Type of Identification Produced: Type of Identification Produced:
CONTRA OR
Na l�iAME I � a � M / ,
License No. i
Address '2 '3O /Vj / O 7 ±ci
Telephone � / -, 76 Fax 300 .� 5--� ` px
l 7 E..
Qualifier Name LLB i ... 0cC `t:-.�. -r-
PROPERTY OWNER
New Construction
Name
A-110 SCI Y GfY 2'6
�
Address
Repair
Home Telephone ?)05 / S (r.:.,. S j , 2 (5
Business Telephone a
Fax
Relocation of Structure
TYPE OF MANAGEMENT (✓ )
New Construction
Enclosure
Alteration Exterior
Repair
Alteration Interior
Demolish
Relocation of Structure
Shell Only
Foundation Only
Add'I Attachment
Other
Add'I Detachment
Other
Step 1.
Job Address: t (o 1\'AG
Address
PERMIT TYPE (✓ )
Building
Electrical
Mechanical
Plumbing
LPGX
Roofing
Fence
Other
PB
PG
Apt.
PERMIT CHANGE (✓ )
Chg. Contractor
Renewal
Revision
Extension
Supplement
Reinspection
ARCHITECT
Name
License No.
Address
Telephone
Fax
Master Permit No.
Subsidiary Permit N
City
Tax Assessed/Appraised Value
PERMIT APPLICATION
INSTRUCTIONS - The following steps must be taken to obtain a permit from the Miami Shores Village:
Complete the attached permit application which must be signed by the property owner and qualifier. Both signatures must be notarized. Please
print or type to allow for a more accurate processing of your application. If roofing work will be done, a roofing application must be submit-
ted along with this permit application.
Step 2. Submit the completed application with all necessary documents to the Building, Planning and Zoning Department for processing. During the
processing of your application, you may be asked to submit additional information.
APPLICATION
Folio Number Description of Work
Lot Block
Subdivision
Current Use of Property Square Feet Units Floors
Proposed Use of Property Value of Work /C9 ()0 Bldg Value
Tenant Information
Zoning Linear Feet
Flood Zone Base Floor Elev.
ENGINEER
Name
License No.
Address
Telephone
Fax
rNi
FOR
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204 Permit Number: PL2002 -286
lam 'Printed: 10 /25/2002
Applicant: ANA BYRD
Owner: BYRD ANA
JOB ADDRESS: 567 NE 96 ST
Contractor LLOYD NORTH DADE SEPTIC TANK SERVIMiNCTactor's Address: 750 NW 107 ST
0
(J Local Phone: 305 - 754 -3375
Parcel # 1132060171580
Fees: Description
FEE2002 -6059 Buildier's Bond
FEE2002 -6060 CCF
FEE2002 -6061 Notary Fee
FEE2002 -6062 Building Fee
Total Fees:
Amount
$300.00
$1.20
$5.00
$80.00
$386.20
Total Fees: $386.20
Total Receipts: $0.00
Permit Status:
Approved
Work: TO REPLACE DRAINFIELD
If there is no Derma narknno
X`' LLOYD NORTH DADE SEPTIC
750 NW 107TH ST.
MIAMI, Fl 33168
PAY
TO THE
OR R OF
04K1i
Washington Mut _a
Washington Mutual nk,
North M,anWlth Avenu Bae Fln anclel Center 1746
12600 N ue Cu
1-800 .788.7000
No Mia F 166 za rastomer Sam
/ 19L: 2now Cu
St/x-(7,44.1 2 47D -
Permit Expiration:
Plumbing Permit
Legal Description: MIAMI SHORES SEC 4 AMD PB 15 -14 LOTS 17 & 18 BLK 99 LOT SIZE
�r7ca7c4 /23/� o Q�i,� Construction Value: $1,8n 0.00 nn
IIIWAVAAWO
DATE
2398
63- 8413/26
ID 'oL�'Q�
$
DOLLARS 8
ll ■ 00 2 3 98" 1: 2 6 708 4 L 3 LI: L9 3111 2009 2 3111 Sll'
,.aavmnn " •- ',IRIMam7n ^. ^MItaeuQant^:-- :"tntlmWm7g4'.- •17MILIaIam7at ^:- = 'rtnaa>UPanr: m : "Strt1 xamals - - � , m 17!" :- •�tm9AbWtl� :- auevaSmnn_'. - - ="'S 'U' an": - -:" •�-
Page 1 of 1
Re- inspection
cation herefor in strict compliance with all
fications that may have been submitted to
> or if the plans are changed without
)onsibility for a thorough knowledge of the
that he assumes responsibility for work done
1s pertaining thereto and in strict conformity
osponisibility for all work done by either
PLICANT: / C L, \AK_) AGENT: L L Qy� A/o/Z=7 / •Lia (.3Z /G
T: y BLOCK: c9 SUBDIVISION: fl/! /M./1/ ji7 .r5 oZC! /Dvj
OPERTY ID #: 1 i . 5:21)6 a—y Section /Township /Range /Parcel No. or Tax ID Number]
O U' i
BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
OVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
.OPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ] NO NET USABLE AREA AVAILABLE: • a0 ACRES
tTAL ESTIMATED SEWAGE FLOW: 4 1 1 00 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2)
(THORIZED SEWAGE FLOW: Al■ • GALLONS PER DAY [1500 GPD /ACRE OR 250q,GPD /ACRE]
:OBSTRUCTED AREA AVAILABLE: (, SQFT UNOBSTRUCTED AREA REQUIRED: O m SQFT
:NCHMARK /REFERENCE POINT LOCATION: F/ ,L N FLOOR OOR / o . 9 '
?4.1:,--
,EVATION OF PROPOSED SYSTEM SITE IS QIFICHS E FT] [ABOVE/BELOW BENCHMARK /REFERENCE POINT
IE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPO ED SYSTEM TO THE FOLLOWING FEATURES:
fRFACE WATER:
� FT DITCHES /SWALES: Nr/ FT NORMALLY WET? [ ] YES J[ ] NO t :L �1
LS: PUBLIC: AA FT _LIMITED USE: _AJA FT PRIVATE: �f3 FT NON- POTABLE: FT
fILDING FOUNDATIONS: J FT PROPERTY LINES: FT POTABLE WATER LINES: / FT
TE SUBJECT TO FREQUENT FLOODING: [ YES [ 10 YEAR FLOODING? /[ ] YES []NO
YEAR FLOOD ELEVATION FOR SITE: FT M NGVD SITE ELEVATION: f'.�Z- CZ M NGVD
)IL PROFILE INFORMATION SITE 1
Color
Iunsell
a vz=
STATE OF FLORIDA
DEPARTMENT OF HEALTH
1 ' ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
ITE EVALUATED BY:
Texture
431-/l
Depth
to
0j4v1D C/ to 77
JSDA SOIL SERIES: 0/( 5f/A..
to
to
to
to
to
to
to
H 4015, 10/96 (Replaces HRS -H Form 4015 (Page 3) which may be used)
;tock Number 5744 -003- 4015 -1)
SOIL PROFILE INFORMATION SITE 2
Munsell Color Texture Depth
/•� T to
');f LLtGU/ 54/k ex) d to
to
to
to
to
to
to
to
USDA SOIL SERIES: V RI/ULIxID
3SERVEU WATER TABLE: A) 4 INCHES [ABOVE / BELOOW] FISTING GRADE. TYPE: [PERCHED / APPARENT]
3TIMATED WET SEASON WATER TABLE ELEVATI r: 30.5V INCHES [ ABOVE BELOW ] EXISTING GRADE.
IGH WATER TABLE VEGETATION: [ ] YES [ ] NO MOTTLING: [ ] YES [/fNO DEPTH: /V01 INCHES
0 7
AIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:,, 0 70 DEPTH OF EXCAVATION: a INCHES
2AINFIELD CONFIGURATION: ( ] TRENCH [e) BED [ ] OTHER (SPECIFY)
EMARKS /ADDITIONAL CRITERIA:
DATE: /U -
Page 3 of 3
Not Approved
STATE OF FLORIDA -
DEPARTM FNT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL
SYSTEM CONSTRUCTION PE
Permit Application Number
:ale: Each b — — PART II - SITE PLAN_
bck represents 5 feet and 1 inch = 2
f • 50 feet. X 3 0
1 Y
y �,�� FiZ/. - - 7-1//-1()Z-- 47 _._
SAC
Title
u� z tYt•
Date
ALL r
HAIYGES MUST BE APPROVED 6 r County Health Department
`1'
PROVED Sy
5.� �+nooiawnk THE COUNTY HEALTH DEPARTMENT mod)
i( 3 I
30 (a l
[
CONSTRUCTION PERMIT FORT
New System [N] Existing System
Repair [ ] Abandonment
APPLICANT•
LOT:
STATE OF FLORIDA 1LJ
DEPARTMENT OF HEALTH ,
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
/ 7 -/ / 2 BLOCK : I
PROPERTY ID #:
0
T
H
E
R
SPECIFICATIONS BY:
4PPROVBD BY:
)ATE ISSUED: 10/Z Z' / iJ Z
PERMIT NO. 0 1 - 30C, 1
DATE PAID: I O - O
FEE PAID:
RECEIPT #: ) 4
(Pi Holding Tank [!"] Innovative
[ i ] Temporary [ ]
c710' -e l3 yYci
PROPERTY ADDRESS: CP 7 /3 , E_ (r 71 l tt S
SUBDIVISION: r 7/ 11 -``+ 1 Lt (15 P C
l 2" �r
119:11"; d_ „-
A i
Ni:S; ;1 C
( tZ0
s ! 30
Pc.
T
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DE AND SPECIFICATIONS
E
T (Of Jr!) ] GALLONS / GPD SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
A [ ] GALLONS / GPD CAPACITY MULTI- CHAMBERED /IN- SERIES [ ]
N [___ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ]
D [3 00 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ _. ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [i] STANARD [ FILLED [ ] MOUND [ ] _
I CONFIGURATION: [ ] TRENCH [� BED [ ]
N '
F LOCATION OF BENCHMARK: i 0, 7 0 r 0 ' C1 4. ` U. t-• • C rQ+J
I ELEVATION OF PROPOSED SYSTEM SITE (3?q0] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [6,1 s/ (]I [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: (N u--" ] INCHES EXCAVATION REQUIRED: [ 3 T ] INCHES
1 L 4 -
/
(✓ ()/ IV r f i- i4 g r - ! �, TITLE:: . Aid C '
EXPIRATION DATE:
424
)H 4016, 12/99 (Page 1) (Previous Editions May Be Used) Page 1 of 3
pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer /Contractor
pt. 4: Building Department
I
ELECTRICAL
TYPE
Minimum Fee
QTY.
TYPE
Dryer
QTY.
TYPE
Outlet, Appliance
QTY.
"I'1 "I'I:
Service Repair
Q"I'1'.
A/C Central 1 -3 Ton
Fan
Dryer Vents, Number of
Outlet, Wall
Ventilation, Cost
Service, Temporary
Air Handler, Tons
A/C Central 4 -7 Ton
Piping, Flammable Liquid
Fire Pump
Filter Replace
Outlet, Switch
Fire Sprinkler System
Signs
Sprinkler Repair
A/C Central 8 -15 Ton
Bath Fan - Vented, #
Fixture - Fluorescent
Pressure Vessel
Oven
Pump and Abandon
Space Heater (kw)
Sprinkler System
A/C Central 16-20 Ton
Cap - Water
Fixture Light
Gas - Appliance
Parking Lot Lights
Pump, Domestic
Spas/Hot Tubs
Supply, AC Well
A/C Central 20+ Ton
Cap - Sewer
Flood Lights
Gas - Natural
Plugmold/Strip
Pump, Fire Stand
Subfeeds, No. of Amps
Temporary Toilet
A/C Window
Catch Basin
FPL - Load Central
Gas - Propane
Posts
Pump, Re- circulate
Swim Pool, Commercial
Temporary Water Closet
Air Conditioners
Clothes Washer
Garbage Disposal
Gas Piping
Range/Range Top
Pump, Replace - Pool
Swim Pool, Residential
Urinal
Chiller
Dental Chair
Generators, etc.
Grease Trap
Receptacles
Pump, Sprinkler
Switchboards
Utility - Sewer
Clear Violations
Discharge Well
Heat Recovery
Ice Maker
Refrigerator, Comm. (p/PH)
Pump, Sump
Temp Serv., Construction
Utility - Water
Compactor
Dishwasher
Low -volt, Burglar
Indirect Wastes
Refrigerator, Domestic
Relay Repair
Temp for Test - 30 days
Vacuum Pump
Deep Freezer
Disposal
Low -volt, Fire
Interceptor
Renew - Temp Service
Roof Inlet
Water Closet
Demolition
Domestic Well
Low -volt, Intercom/Teleph.
Laundry Tray
Repair Circuits
Septic Connection
Water Heater
Dishwasher
Drainfield, 4" Tile/Res.
Low -volt, Television
Lavatory
Service, Number of Amps
Septic Tank
Water Heater New
MECHANICAL
Tl'1'1'.
Minimum Fee
QTY. :TV'I'I
Condensate Drain
QTv. TV"1'E
Generator
QTY. "I'1"1'E
Refrigeration, Tons
Q'I'1".
A/C Central, Tons
Cooling Tower
Heating Strips, each
Vent Hood, Cost
A/C Wall/Win. Tons
Dryer Vents, Number of
Paint Booth
Ventilation, Cost
Air Handler, Tons
Ductwork, Cost of
Piping, Flammable Liquid
Periodic Inspections
Filter Replace
Barbecue
Fire Sprinkler System
Process/Pressure Piping
Sprinkler Repair
Bath Fan - Vented, #
Fireplaces, Number of
Pressure Vessel
Pump and Abandon
P I LU1\IBING
'I'V'1'F:
A/C Condensate
QTY.
TV'PE
Drains, Roof
QTY.
"1'1'PE
Miscellaneous Fixture
Q"I'1".
Tl"I'F.
Soakage Pit
QTV .
Bath Tub
Drinking Fountain
Miscellaneous Repairs
Solar Water Heater
Bidet
Filter Replace
Pool Piping
Sprinkler Repair
Cap - Fixture
Fountain
Pump and Abandon
Sprinkler System
Cap - Water
Gas - Appliance
Pump, Domestic
Supply, AC Well
Cap - Sewer
Gas - Natural
Pump, Fire Stand
Temporary Toilet
Catch Basin
Gas - Propane
Pump, Re- circulate
Temporary Water Closet
Clothes Washer
Gas Piping
Pump, Replace - Pool
Urinal
Dental Chair
Grease Trap
Pump, Sprinkler
Utility - Sewer
Discharge Well
Ice Maker
Pump, Sump
Utility - Water
Dishwasher
Indirect Wastes
Relay Repair
Vacuum Pump
Disposal
Interceptor
Roof Inlet
Water Closet
Domestic Well
Laundry Tray
Septic Connection
Water Heater
Drainfield, 4" Tile/Res.
Lavatory
Septic Tank
Water Heater New
Drains, Area
Meter Set (Gas)
Sewer Connection
Water Re -pipe
Drains, Floor
Minimum Fee
Shower
Water Service
Drains, French
Miscellaneous Equipment
Sink
Well, Supply
Page 3
PERMIT APPLICATION
INSTRUCTIONS: Please indicate the type of work being performed and quantity(ies) in the space provided below.
RECEIVED AND REVIEWED BY: DATE:
Page 4
OFFICE USE ONLY
❑ OWNER - BUILDER FORM
(Attach)
❑ FIRE DEPARTMENT
APPROVAL (Commercial /
multi - family)
❑ CONCURRENCY
(New Construction)
❑ OTHER
(Specify & Attach)
$3.00 per page (Scanning Fee)
Miami Shores Village
Bond
Metropolitan Dade County (C.C.F.) $
Inspector State Educational Fund $
State DCA (Radon) $
Code Enforcement Fine
Zoning Review
Notary
❑ IMPACT FEE
(New Construction)
$
SECTION
Zoning
Electrical
Mechanical
Plumbing
Fire
Public Works
Structural
Building Official
BY
DATE
PERMIT APPLICATION
CHECKLIST
O PROOF OF OWNERSHIP
(Attach)
❑ HRS / DERM APPROVAL
(Septic / Sewer)
❑ OTHER
(Specify & Attach)
( x . f t. x/1000
(¢.005 / sq.ft.)
(¢.01 /sq.ft.)
❑ CONDO ASSOCIATION APPROVAL
(Attach)
❑ BPR APPROVAL (Restaurants)
❑ CONTRACTOR REGISTRATION
(On File)
PERMIT FEES
TOTAL $
ISSUING OFFICIAL
REVIEWED AND PREPARED BY: DATE:
CONDITION OF APPROVAL
Revised July 2001
10050 N.E. 2ND AVE., MIAMI SHORES, FL • (305) 795 -2207 • FAX (305) 756 -8972 • http : / /www.miamishoresvillage.com
•
•
7
. • ...■ : ...1r- ' •2 ig,2„,ve.
, ,...._
\ • r1.•$73';' 4:4.' t'.V.:,.. t,
.. . ... 4
_. .. . ,,,..-, -Is .,..gr i fc c".• !.: 42141-
,.,..,,,if.),4•47-ip:,:i,. - - ' -
AVS .
.?,
g _.... 4-- - - 11 - + - 4 4 . ... 0,- ,e
.10, s's4A, 4 .1 4,1 —.., At: L 5
- , ' ' ' ." ` ' " 7 , " • • '• 0 Isrr - - ,. • ..
ff i. ,,,
., ..t-,•P1.1: 3 -,-.....,'
'''''.it;T:1•:"...Zt:
...,,-
•
BUILDING
ELECTRICAL
PLUMBING
ROOFING
Owner of
Building ! '
0
❑
CONTRACTOR or BUILDER
MIAMI SHORES VILLAGE, FLORIDA
Date 19 —f
PERMIT N? 10673
Work to be performed under this Permit
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot 11
11 Bl
Contractor's
License No.
Subdi-
vision
Sq Ft
Value of 11 Amount of
Project $ 11 Permit $
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the applica-
tion herefor in strict compliance with all ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specifications and that he assumes respon
sibility for work done by his agents, servants or employees.
Signed • (INSPECTOR) BY
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
In accepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
BY AUTHORITY
BUILDING ❑ MIAMI SHORES VILLAGE, FLORIDA
Date— t { 19_ 4
ELECTRICAL ❑
PLUMBING i PERMIT N9 10749 Contractor's �> ?
ROOFING ❑ License No. r 1 /
❑ Work to be performed under this Permit
Owner of
Building
Architect
Contractor
or Builder
Legal Lot
Description 11 Bl.
Address of
Building
Subdi ,
vision
SgFt �•
Value of Amount of
Project $ Permit $ i>"7"
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the applica-
tion herefor in strict compliance with zll ordinances pertaining thereto and with the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above assumes the responsibility for a thorough knowledge of the ordinances and
regulations pertaining to the work covered hereby whether skown on the plans or drawings or in the statements or specifications and that he assumes respon-
sibility for work done by his agents, servants or employees.
Signed• (INSPECTOR) BY
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulation,
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village.
In accepting this permit I assume responsibility for all work done by either, myself, my agent, servant or employee.
CONTRACTOR or BUILDER
BY AUTHORITY
e s .
Date /0 ®; d/ °
Legal Description
FEES: PERMIT 0 RADON
PERMIT APPLICATION FOR MIAMI SHORES / VILLAGE
Job .Ad 56 7 A/ Tax Folio r, O b 01 s7 � S 11
„e/V (), %---t4 it
Owner/Lessee / Tenant 0° 1� p � r ,
Owner's Address 5 A/ . - c
Contracting Co. � 0 < C.. . �� ` f (69'e'
jrd . 4,41
Qualifier
State # Municipal # Ins. Co.
Architect/Engineer
Bonding Company
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION /e e L,F'/ bait.
Square Ft. 36rn Estimated Cost (value) ( 0 0
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.
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 amytiiprize the above -named contractor to do the work stated.
Signature of o Date
Notary as to Owner and/or Condo President Date
My Commission Ex • ires:
STEPHEN E. COCKING
41 MY COMMISSION # DD 031747
EXPIRES: June 20, 2005
'4,4/ Bonded Thu Notary Public Under writets
APPROVED:
Zoning Building
Mechanical Plumbing
Historically Designated: Yes
Competency #
Address
Address
C.C.F. 1 , o 1) NOTARY 5-9 ° 1) BONDS 17 O
TOTAL DUE 4% 4
No
5 °IS
Phone /'®a' -02 se 72
Master Permit #
Address ,0r2 d 2 /}i6✓• 2 l
ss# - - Phone ?e 651- 7t r7
otary as to ontracto or Owne - Builder
My Commission ExOrek: ' �< ; •
Electrical
Structural Engineer
Notes: (;7)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEVVAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Scale: Each block represents 10 feet and 1 inch = 40 feet.
q
n_ e
rqr:
,/
•
DH 4015, 10/96 (Replaces HRS-I-1 Form 4015 which may be used)
(Stock Number 5744-002-4015-6)
PART II SITEPLAN
Permit Application Number
I \-
e
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
u \•
V
,
Site Plan submittecrby:
,
Plan Approved j \ , Not Approved ^\. , Date
i
,
By - ) /-,
-. r __, -- ,,, ,, ,, ,,-, _:) County Health Department
Page 2 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND 'DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System
[ X ]Repair [ ]Abandonment
]Holding Tank
]Temporary
APPLICANT: Byrd, Michael AGENT: SR0931119, COCKING MSTEPHEN
PROPERTY STREET ADDRESS: 567 NE 96 St Miami FL 33150
LOT: 17
BLOCK: 99 SUBDIVISION: Miami Shores
[
[
[Section /Township /Range /Parcel No.]
PROPERTY ID #: 11- 3206 - 017 -1580 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 750 ]Gallons SEPTIC TANK MULTI- CHAMBERED /IN SERIES: [Y
A [ 900 ]Gallons MULTI - CHAMBERED /IN SERIES: [Y
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
D [ 0 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 300 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ ]STANDARD [ ]FILLED [ N ]MOUND [ N ]
I CONFIGURATION: [ N ]TRENCH [ ]BED [ N ]
N
F LOCATION TO BENCHMARK: Finished Floor of Existing Residence Elev. 10.9' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 2.7 ] [ FEET ] [ BELOW]BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 4.5 ] [ FEET ) [ BELOW]BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 22.0 ] INCHES
OTHER REMARKS:
SPECIFICATIONS BY: Paul Levelt Andre, P.E
Invert Elevation Of the Drainfield to be no less than 6.87' NGVD
Bottom Elevation of the Drainfield to be no less than 6.37' NGVD
This permit is not for addition.
APPROVED BY: Andre, Paul T ITLE: EH Supervisor Dade CHD
DATE ISSUED: 10/30/01 EXPIRATION DATE: 1/28/02
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5794 -001- 4016 -0) [ ostds_cons_4016 -1]
TITLE: \..(tri - q
CENTRAX #: 13 -SG -10777
DATE PAID:
FEE PAID : $
RECEIPT
OSTDSNBR : 01 -3366- -R
] Innovative Other
)
Page 1 of 2
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
10050 N.E. 2nd Avenue • Miami Shores, Florida 33138.305- 795 -2204
Date : i�^� ' ' Job Address y U lid ' ', 1 /It"- ' Tax Folio
Legal Description 7 e".' -R ' (f'">" ' . " Historically Designated: Yes No
Owner /Lessee/Tenet Pe"( >_ �� ' Master Permit # '� gi ea a pG.ag3oa ' / & J f-
�
� , /':-,, ti = Phone f l'
Owner's Address 4.,{/ /':-,,
l
Contracting Co.
Qualifier
State #
inn
Notary as to Owner and/or Condo President
My Commission Expires
FEES: PERMIT v ' �✓ RADON
APPROVED:
Zoning
Mechanical Plumbing
' ] Address L ' / /4/,
SS#
C.C.F
. `( Phone /,� 5 l
Municipal # Competency # Ins. Co.
IF THERE IS NO PERMIT PACKAGE ACCIESSIBLE ON THE JOB SITE FOR INSPECTORS TO VERIFY,
THERE WILL BE NO INSPECTION. RE- INSPECTION FEE IS $50.00 AND MUST BE PAID IN ADVANCE
BEFORE CALLING FOR ANOTHER INSPECTION.
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING
WORK DESCRIPTION:
Square Ft. 1), Estimated Cost (value) 1
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 ANY 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). 1 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 all disciplines.
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.
NOTARY
Date Notary as to Contractor or Owner Builder
My Commission Expires
Signature of owner and/or Condo President Date Signature of Contractor or Owner Builder Date
3 • BOND
TOTAL DUE 36(P 2-D
Date
Building Electrical
Structural Engineer
Miami Shores Village Plumbing Permit
10050 NE 2nd Avenue
Phone: 305 - 795 -2204 Permit Number: PL2002 -164
A- Printed: 6/25/2002 Page 1 of 1
Applicant: ANA BYRD
r( Owner: BYRD ANA
JOB ADDRESS: 567 NE 96 ST
e \ , Contractor MR C'S SEPTIC TANK Contractor's Address: P 0 BOX 693239
l' Local Phone: 305 - 651 -7859
1 Parcel # 1132060171580 Legal Description: MIAMI SHORES SEC 4 AMD PB 15 -14 LOTS 17 & 18 BLK 99 LOT SIZE
Fees: Description Amount
FEE2002 -3560 Building Fee $80.00
FEE2002 -3561 CCF $1.20 Total Fees: $386.20
FEE2002 -3562 Buildier's Bond otal Receipts: $0.00
Q $300.00
FEE2002-3563 Notary Fee $5.00
Total Fees: $386.20
PAY
TO THE
ORDER OF
Permit Status: Approved Permit Expiration: 12/22/2002 Construction Value: $1,900.00
Work: TO REPLACE DRAINFIELD
If there is no permit package accessible on the job -site for inspectors to verify, there will be no inspections. Re- inspection
MR. C'S SEPTIC & DRAIN, INC.
OPERATING ACCOUNT
P.O. BOX 693239 305- 651 -7859
MIAMI, FL 33269 -0239
Washington Mutual
Washington Mutual Bank, F8
Miami/199th Street Financial Center 1719
175 NW. 199th Street 1.800.788.7000
Miami, FL 33169 24 noun Custom °, Service
r ^' - 0
FOR
11 '00547711' 1 :267084 L3 II: 313 3 3013 2111011'
DATE
$ ✓
24, DOLLARS
63- 8413/2670
I
cation herefor in strict compliance with all
ifications that may have been submitted to
s or if the plans are changed without
ponsibility for a thorough knowledge of the
that he assumes responsibility for work done
)ns pertaining thereto and in strict conformity
responisibility for all work done by either
'PLICANT:
)T:1)
JTHORIZED SEWAGE FLOW:
)OBSTRUCTED AREA AVAILABLE:
SITE EVALUATED BY.
STATE OF FLORIDA
DEPARTMENT OF HEA1,TH
ONSITE SEWAGE'DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: 9 ' SUBDIVISION:
tOPERTY ID #: 1 1_ 3 2 . 06 '- o / s e b.
) BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
ZOVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
tOPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ] NO NET USABLE AREA AVAILABLE: ()'may A�cR�FSi
)TAL ESTIMATED SEWAGE FLOW: ___ avo GALLONS PER DAY [RESIDENCES -TABLE 1 OTHER -TABLE 2)
:NCHMARK /REFERENCE POINT LOCATION:
.EVATION OF PROPOSED SYSTEM SITE IS 9,1 [INCHES
HE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE
JRFACE WATER: FT DITCHES /S ALES:
ELLS: PUBLIC: FT LIMITED USE: rah. FT
JILDING FOUNDATIO S:
ITE SUBJECT TO FREQUENT FLOODING: [ ] YES
0 YEAR FLOOD ELEVATION FOR SITE: ki
OIL PROFILE INFORMATION SITE 111011 011 (4 •
FT PROPERTY LINES:
Munsell olor Texture Depth
to
tom
to
to
to
to
to
to
USDA SOIL SERIES: /
W
BSERVED WATER TABLE: Pi INCHES [ABOVE / BELOW]
STIMATED WET SEASON WAT TABLE ELEVATION:
IGH WATER TABLE VEGETATION: [ ] YES [lJ NO
)H 4015, 10/96 (Replaces HRS -H Form 4015 (Pogo 3) which may be used)
Stock Number: 5744 -003 - 4015 -1)
AGENT:
SOIL PROFILE INFORMATION SITE 2
PERMIT # 00A) -- �& r
[Section /Township /Range /Parcel No. or Tax ID Number)
GALLONS PER DAY [1500 GPD /ACRE OR 2s go GPD/ACRE)
SQFT UNOBSTRUCTED AREA REQUIRED: 611Z SQFT
[ABOVE/ ELO91� BENCHMARK /REFERENCE POINT
PROPOSED SYSTEM TO THE FOLLOWING FEATURE :
ern) FT NORMALLY WET? [ j YES [ NO
P$ZVATE: FT NON- POTABLE: r 1 FT
! p FT POTABLE WATER LINES: E5 FT
[INO 10 YEAR FLOODIN, ? [ ] YES [ 4"NO
FT MSL /NGVD SITE ELEVATION: U6'2.• FT MSL /NGVD
w 41
, MAMMA
Munsell ' Color Texture Depth
to
0 to
to
USDA SOIL SERIES s Z (O J L ..J
to
to
to
to
to
to
XISTING GRADE. TYPE: (PERCHED / APPARENT)
_ INCHES [ ABOVE / BELOW ] EXIS ING GRADE.
MOTTLING: [ ] YES [1].... N0 DEPTH: 4 INCHES
0 7 0 DEPTH OF EXCAVATION:
INCHES
;OIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
IRAINFIELD CONFIGURATION: [ ) TRENCH V] BED [ ] OTHER (SPECIFY)
EMARKS /ADDITIONAL CRITERIA:
DATE: fO 20 a-
Page 3 of 3
1/e: Each block represents 10 feet and 1 inch = 40 feet.
Notes:
Site Plan submitted
Plan Approved
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION P
Permit Application Number
13-
fYlsnl
7I +1---
t e K & t fi L (cvD
tkvvteA
ANL 6°1
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015, 10/96 (Replaces HRS -H Fomi 4015 which may be used) Page 2 of 4
(Stock Number: 5744 -0024015 -6)
PART II - SITEPLAN
Not Approved
D
A5 76 Sft-t4
, (51 () plc
Date C/26/
County Health Department
T
A
K
D
R
A
I
N
F
I
E
L
STATE OF FL PERMIT # 62 1; l kc' [
e , _ zoo Z
?l ..1 != a DATE PAID
DEPARTMENT �F %�' � • 4 �:J ,:: ., �
ONSITE SEWAt J. SYSTEM .. ! ..FEE .PAID 7A _ j
CONSTRUCTIO' i ,. RECEIPT tic, zit
Authority: Chapter 381, . FS & Chapter 1OD -6, FAC ! 3 ( ? Cr O
CONSTRUCTION PERMIT FOR:
[ 0 New System [. 1 Existing System .[ 0 Holding Tank .>[ =�J] Temporary/Experimental
[ )6 Repair [ J) Abandonment [ p) Other(Specify)
'
33 I 3 P
PROPERTY. STREET ADDRESS:. • �n 7 • t ,
LOT: BLOCK:
PROPERTY ID #:
l ] - 3 20 • lJ 1 7 - / . [ OR TAB :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 ISSUE:.' ALL OTHER
PERMITS EXPIRE ONE YEAR FROM THE DATE OF: ISSUE. DEPARTMENT .0E HEALTH APPROVAL 'OF, SYSTEM DOES
NOT GUARANTEE 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'THIS7 PERMIT .'BEING MADE NULL AND VOID*"
SYSTEM DESIGN AND SPECIFICATIONS
[ 6 ' ��g [GALLONS / GPI)] SEPTIC TANK/AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES :( ]
[ CO Q ) (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 [ ] PER.24 HRS NO. OF PUMPS: ( 1
[' SQUARE FEET PRIMARY DRAINFIELD SYSTEM
SYSTEM
[ — J SQUARE FEET
TYPE SYSTEM:
CONFIGURATION
LOCATION OF BENCHMARK: I d t f Q I . �] • ) .
ELEVATION OF PROPOSED SYSTEM SITE [ 32.q [
BOTTOM OF DRAINFIELD TO BE ( 62,14()
FILL REQUIRED : (
SPECIFICATIONS BY:
APPROVED BY
DATE, ISSUED: '.
•
(vf STANDARD . [ J FILLED
( 1 TRENCH [ , ,BED
) INCHES
OH 4016, 10196 (Replaces HRS -H Form 4016 [page 11 which may be used)
(Stock. Number: • 5744 -001- 4016 -0)
SUBDIVISION:
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER)
.•J MOUND
1 •
FT]; [ABOVE/ BENCHMARK /
/FTJ [ABOVE /,;ice= BENCHMARK/
EXCAVATION REQUIRED: 1.34 1 INCHES
1.1 t' ...4 . � fi .� ^. 1_7 V
L44 1...... ;s`4 , .8 's.,:e.l..?� ::.�a B'T`•..:,f Y.u02n_.b.`;i,� r°A. ®Vei
50t
cl
APPLICANT:
AGENT:
PROPERTY ADDRESS:
LOT: L BL,OpX= ! SUBDIVISION:
1
l
1
l
l
l
l
l
l
l
1
EXPLANATION OF VIOLATIONS
FILL
[22]
[23]
[2
[25]
[26]
U
1
/ EXCAVATION MATERIAL
FILL AMOUNT 4
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEMENT MATERIAL.
REMARKS:
•
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
ss:s ssauaaasazsaasaaaaa
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND
za ::esss
TANK INSTALLATION SETBACKS
[ ] [01] TANK SIZE [1] rV(; [ G , . [2] [03 l [] FT 27 SURFACE WATER F
[ ] [02] TANK MATERIAL _L v G ,' _ / [ ] [28] DITCHES FT
FT
1 1 [03] OUTLET DEVICE t � r' ( l [29] PRIVATE WELLS FT
C WELLS [ l [04] MULTI- CSAMAERBD [ Y'J N ] [ f$ l ( 30]
31l IRBI WBLt+S FT
[ ] [06] OUTLET lILTER ( ] [32] POTABLE WATER LINES FT
[3-] ] [06] LEGEND N% ' [ 1 [33] BUILDING FOUNDATION ,S FT
[ [07] WATERTIGHT [ ] [34] PROPERTY LINES (o FT
[ ] ( 09 ] DEPTH TO LID , 1 I [ 35] OTHER 4 .S_ FT
[ ] [ ] r� �i �? {;
DRAINFIELD INSTALLATION { , 3 (, U
[10] AREA [ 1 y d)' a l [ 2 ] _ _ SQFT
[11] DISTRIBUTION BOX HEAD
[12] NUMBER OF DRAINLINES
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER
[16] ELEVATION [ABOVE /BELOW] BM
(17] SYSTEM LOCATION ` /�
[18] DOSING PUMPS
[ 19 ] AGGREGATE SIZE t f S 1). 6 - . 7
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPTH
t
CONSTRUCTION '[APPROVED /DISAPPROVED]: _1 =14„.
- z- `
FINAL SYSTF.MS,1APPROVED / DISAPPROVED] s ) r, ).
DE 4016,.1® /9.7—(Previous Editions Nay Be Used) J '
Installer / Contractor
S L J. V j PROPERTY ID is! ' J) a • 4 17 fS i'O
l
l
l
i
l
V -'9
}!�',% C
PERMIT NO
DATE PAID:
FEE PAID:
RECEIPT #$
- 506
ra 2 -
-r� oO
MUST BE CORRECTED.
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43 ] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] !DIAL SITE GRADING ,
(47] CONTRACTOR � � f ., 0 / 1 , am
[48] OTHER
AB ONKE NT
] [49] TANK PUMPED ___/__/
] [50] TANK CRUSHED 4 FILLED
OLD DATE: ic ,2 S r% 7--
CND ! J =a'�
Page 2 of 3