680 NE 97 St (12)[ l
[ �]
PLICATION FOR:
Mew Systm
Repair
• STATE OF FLORIDA
DEPARTMENT OF ZEALTR
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
[
[ II %` "andonment
APPLICANT: tR Q b P �-1 ( 1 t 6 4 1 y'l
] Iciottimg Bffuttam Q
AGENT: If' u
MAILING ADDRESS: q, 7 - A) car ICI 74 1 it HJ eDas BI u S t:2C0"' 41 d i i • 0 1 6 3
TO . 18 COMPLETE ICY APPLICANT OR APPLICANT'S S AUTEORIB D AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 888.105(3) (m) OR 489.552, FLORIDA STATUTES.
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PROPERTY INFORMATION
LOT: I c DLOCL: MEDI UMW: /4 / AA 1 S
PROPERTY It Os /13.061-0/ - MEMO:
PROPER! SIDE: a R RCL'ms
IS SEWER AVAILABLE AO DER 381.0065, PO? [ 4 / 12 D
9 6 " At - 1a 96 • o (Uct)
7U I fu 5 f iue OOP RJ E q 7 •,r " 27�e
PROPERTY, ADBRE32 s, 246ga
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION [p(1 RESIDENTIAL
Unit Typo of I o. of
No Establishment Bedroom:
1 SIR.
2
3
8
[ ] Fioor /] gaaip mit Drains
SIGNATURE
DH 4015, 10/
3
— Page 1 (Previous editions may be used)
Stock Number: 5744 -001- 4015 -1
±aiding Tank Q ➢ Innovative
D Temporary [
SUPPLY: Q ] PRIVATE PUBLIC [ p0 ag2O® ®G>P% [ p2O000PD
D ISTANCE SEWER: P t /// Fig
I�uai11 Commercial/Institutional System
Area Sqft °able 8, Chapter 64E-6, FAC
Other /Specify)
P8,PJ1IT
DATE PAID:
FEE PAID:
1
/ L(3 /
T>8II.1 PEO a 6 5/
PLATTED: /c/(,0
a /E3 OR EQUIVALENT: Q Y /(01
Q D COMMERCIAL
33 I
g5GTFrisr
Page 1 of 3
ONSTRUCTION PERMIT FOR:
]New System [ ]Existing System
X ]Repair [ ]Abandonment
PPLICANT: Frame, Robert
DT: 1
(STEM DESIGN AND SPECIFICATIONS
[
[
[
ECIFICATIONS BY: Icaza, Carlos
PROVED BY: Icaza, Carlos
TE ISSUED: 7/7/04
'Existing 900 gl. septic tank to remain.
Install 300 sq.ft. of drainfield.
'Invert elevation to be no less than 7.83' NGVD.
'Bottom elevation to be no less than 7.33' NGVD.
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
]Holding Tank
]Temporary
AGENT: SA0021077, Bolanos Jose
ROPERTY STREET ADDRESS: 680 NE 97 St Miami Shores FL 33138
BLOCK: 100 SUBDIVISION: Miami Shores
[Section /Township /Range /Parcel No.]
EROPERTY ID #: 11- 3206 - 017 -1610 [OR TAX ID NUMBER]
'STEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
EPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
ERIOD. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT,
SQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS
ERMIT BEING MADE NULL AND VOID. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
)MPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
900 ]Gallons SEPTIC TANK
0 ]Gallons
0 ]GALLONS GREASE INTERCEPTOR CAPACITY
0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS
[ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ 0 ]SQUARE FEET SYSTEM
TYPE SYSTEM: [)'n ]STANDARD [ N ]FILLED
CONFIGURATION: [r N ]TRENCH [? G ]BED
LOCATION TO BENCHMARK: Top of Bottom Floor, 12.10' NGVD.
ELEVATION OF PROPOSED SYSTEM SITE [ 3.1 ] [ FEET ]
BOTTOM OF DRAINFIELD TO BE [ 4.8 ] [ FEET ]
FILL REQUIRED:[ 0.0 ]INCHES EXCAVATION REQUIRED: [
'HER REMARKS:
TITLE:
[ ] Innovative Other
[ NA ]
[0 ]DOSES PER 24 HRS # PUMPS[ 0
[ N ]MOUND [ N ]
[ N ]
[
[
CENTRAX #: 13 -SG -21421
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 04 -2371- -R
MULTI - CHAMBERED /IN SERIES: [Y
MULTI - CHAMBERED /IN SERIES: [Y
BELOW BENCHMARK /REFERENCE POINT
BELOW BENCHMARK /REFERENCE POINT
20.0 ] INCHES
r
T7113 PERMIT LS NOT FON ADDITION(S)
THE SEPTIC p
GY'+�lt `Zd'Y'�RO aY �'�.:�:c. ^.. o:.. x A9 �5 e` �'1�, �C 7"'� A C�r� �,
s.W L EIui� p���l �l'�i �2'o 9 ) r .t .. � ;1 SOLID
�. ..J is if 1Y�p: Y
r ��UT LL'p YF.E
‹ i 4 -73
/ TITLE: Engineer I Dade
EXPIRATION DATE: 10/5/04
CHD
By
,;
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION ETAI
•
Permit Application Numbe • e
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Site Plan submitted b :
Plan Approved
DH 4015, 1W96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-6)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
bp..0 OU elk (/ou/,iu
obi 11
Signature
k
Not Approved
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Notes: Ro (-1 -620 0e q7 HI A t1-4 Norte c ri
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Title
Date 7-
County Health Department
Page 2 of 3