590 NE 96 St (8)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date C k ` 1 `\ 1C3 Job Address S '\o N) L t-;7 Tax Folio // _ 7 t , ' I't Bog
6 `7f g 3214_1/
Legal Description )4'
Owner / Lessee / Tenant R OL l -'� -
Owner's Address S Kf- q(0 ST.
Contracting Co. RQCO I2.02s -Y Address
Qualifier 1CA"‘Wel- Qi 0 /
State !i 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 712gLMINA `:- -
Square Ft. 4 FS
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
icable laws regulating construction and zoning. Furthermore, I
be done in compliance w t
authorize / the above -named
all
SS#
SignAure of owner and /or Condo President
Date:?//6 /9
I0
/ YW
Nary as to Owne
My Commission Exp
** *
APPROVED:
*
Mechanical
JOSEPHINE CHURCH
FEES: PERMIT O, DD RADON C.C.F. /iPD
Zoning
o» to do the work stated.
Buildin
Master Permit 4t;ye%
( o2z SLo S c i' dYIl .t '114
- - Phone 1 Glv UR I
Estimated Cost(value) l S $0U CDC:
Signature
Date:
4
Co
Phone 7S`1 " ()
of Contractor or.
v
Notary as t actor or Owner- Builder
My Commission Expires:
* fkindad Thru Titay Fain • Insdlanca Inc. * * / D *
1
NOTARY .4 TOTAL DU
Fire Other
Electrical
Engineering
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION 'PAI MIT //��
Permit Application Number 7 3 TR ) v
.........»..... M_ .................. ...«- ...MN...M................. _..__..PART 11 - SITE PLAN
■■ i..■ a■■/■ a .■ a: •■....a■iiiaiuiiiiiiiiiiiii■■■.
■.■■■..■■.■a..11■■■■■■■r■■■■.■ ■■...a.■aa.■.■■■■
■■■■■■■■■■ II ■a■■■ ■ ■M.s■■ ■.,$s..a..■.■■ ■.■ i..
■omE■■EEEE■■EEIEE■ mwom ummi mummo E.E
■M■.■■..a■ ■.r ■11■ ■■!■■■i.■m■.■ a ■M■■ ■■ ■a■.■.■ ■■
..■a■■■■■■...■ II■ = . .. ■. ■ ■ ■ ■ ■ ■.. ■ ■■ ■ ■ ■■■■ ■■ ■.■ ■■
..u.u.......• lm •a..iiiiiiaiiiiiOMINOiiiiwiaiii
■■■■■■.■■■■..■.■ ■ .■■ ■.■.■.i...■s■.■■s■ ■.a.■ ■.s■
■.■■■■■■. .■.■■.■■■ ■■.1■■■■■■n.■a■.IS■■■.■a.■■w■.
■■
..■. ■..aim■../.■■ ■■ a ■.■wm ■■■..M■■a■■■■a■■■
■■ ■■ ■■■ ■... ■s.■nE■.■ ■ JU�■ ■ ■ ■ ■■■■■■.i■■■■■
■ ■ ■M■■■ ■aa■ ■■. ■ ■. Nu ■\
� •■.y_.■■■■■■■■■...■.■■.■
EE - E • -- =i E- na- i--- -mommommmum mop
n
I....... ■ ■.._1■■... .
■ ■ ■.a11 ■ ■ ■■ ■ ■ ■V!1. ■■.. ■ ■.. ■.a
.s■ ■sal.■.■ ■.n ■■.....■■ a
■■■■.■■a■.■■■II■■..■
. . ■
some ..■
■.-...am! ■ut�r■ ■■
numummummomminuam lulu •au.uw ■■ma . ■�
. cIF =-
mommiummemimmimmumw
■. ■.■ ■iumwmom SI.0 - �: p _ :: ■: Ulan ; ...
I■ /■. ■ ■.. ■ ■a.■ ■ ■■ ! •! : ■/ • a�G�
I■■■■■ ■■a■ ■a■ ■ H ■iii r■ ■
I ■r■■ ■■a... ■.mma■�■ . ■. ■a a ■ ■■ ■
I■■■ Mama■ ■■ ■a■ ■i a■■■ mar a.■ ■ r
I. ■a ■. ■ ■■a.a. ■ ■!■ �� : ;;F • � iiii
• URRSE: Mimi. ■■ muminpummg ■■■■ ■■ I Iii
■Mama■■ ■ I 1 �
1ua. ■r.■■ u . ■m■ -t'�-' . i_ i■rl .
s. ■Ei ■aan = mumumummessammum
OMMINIO p. 1p min
1 1.15mmomm.m Willing. in _
Inn ------------- - - ■..■
a ■■■ a■■ ■■ . ■
-- .....■■. --/■Maim. . _�..
■■ ■ {� f�
amp u mumps am
■■■■ ■■ ■ ... E �..._ • 11111111 1 1 1 1 11111110: ■ :: .' I i • . ■111
■■ ■ ■■■■■
w ■
■..■■■.i■ Li_
■a.w.■ ■.■i 11:1:
11111 ■„ ■ ■ •
■ i■■■.■■li ma■ ■■sua■■■as■!■!■a■ia■ilimpmemmem iiiii
...■■ r ■■■■•■■■■ i�v/ a■ ■..■a. ■. ■ ■....11■Ea ■ ■ ■a!_.■■■.■
■!■■ a. aM■.■ r. rrl ] ■i ■ ■M ■.a ■..■.a ■ ■a■\'. ■ ■■■ ■■. ■ ■.■■
E EEEE E EaIupadsmommEI. . . E E EE EE..... a• ■ •••t �•
•
. aaa■ ■ ■.■.■■■■ ■ ■ / ■ ■■■�.■ ■E■■■■.■■■.
■r■■■■
■!■■■.■ �� ■ ■ ■ ■ ■i ■. a■m
tea•!. ■ ■.....■ ■...■■aI
..■r■- .m....�T ••■■. ■...all ■a■■ ■M.■
=EEU .■.R..■■ ■ ■m- ■■ ■■a■■
■a..yl /J ■M.a■
■■■■■•.■■a. r. i :Inr
smmem ■ ■ ■■a.11■M fputurtram E!%t ■. m
■ ■■■■ ■/■
IE iE ■.■■ ■ ■.. "■ ■1■..a ■r• ■7■ ■ ■ ■.1I I.II.l.■ ■vii■■.....
a■ ■ ■■ ■ r.■ , ; 1 .■ran .,, •o•i■■■■ ■■_■■I ■ ■...E..
EO :EEICOMMEEIr EECEEE Ri EEE.EE..
■E ■ ■■. ■.■■.w/l.■■■ ■■■.E.■■■...■ .
■ E■
* ■s ■ ■ mom. mmm
■a■.■ ■Ne ■■■■ =■ ■aa..■an■■ = =E /■. ■
— IOW I MO ■.•■ ■a■ ■■ ■.■a.EI =■■!.\E�.■ ■.a■i ■E■ ■E ■ ■w li g
IS ■.■i.■. ■■ ■. * .. t
•' • '�•� ■
��� =Ca . = +Oro OE:::: T
•. I a i. . •
• E imi■ .
■i/.
mumillimuu 1
■a
A
r7
otes:
,SOU Q6 rr
to Plan Submitted b
rtA
an Approved V"
Not Approved
t"* --d; I
rrhE
Date 7-2-P,
t.
APPLICATION FOR:
( 3 New System
%\ Repair
APPLICANT:
AGENT:
LOT:
PROPERTY ID 1:
PROPERTY SIZE:
1
2
3
4
STATE OF FLORIDA ()%
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
=SITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT •
Authority: Chapter 381, FS & Chapter 10D -6, FAC
BLOCK:
DIRECTIONS TO PROPERTY:
9.4- g
[ j Existing System ( ] Holding Tank [ ] Temporary /Experimental
[ 3 Abandonment ( ] Other(Specify)
/ r...Q 4e06
NAILIN ADDRESS I /.0 s-Sca ? Ar <
esaaaa
MOO aaaaa
TO BE COMPLETED BY APPLICANT OR APPLICANT AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION (IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED)
] Garbage Orinders /Disposals
] Ultra -low Volume Flush Toilets
SUBDIVISION:
BUILDING INFORMATION ( 3 RESIDENTIAL
:nit Type of No. of
establishment pedrooms
ACRES (Sgft /43560) PROPERTY WATER SUPPLY: ( ) PRIVATE (e0 PUBLIC
PROPERTY STREET ADDRESS: 5 F 0 Jr? -
Building
Area Saft
(
( ) Spas /Hot Tubs
IRS -N Fore 6015,_Mar92 (Obsoleted previous editions which may not be used)
j COMMERCIAL
1 Persons
&ervsd
PERMIT #
DATE PAID
FEE PAID $
RECEIPT 1
TELEPHONE: g‘--fl _3,.
DATE OF
SUBDIVISION:
[Section /Township /Range /Parcel No.) ZONING:
Business Activity .
For Commercial Only
/..foLe
( j Floor /Equipment Drains
( ) Other (Specify)
DATE: •7 2— F../' .
P&a.1 of 3
APPLICANT s /4 dust._
LOT: BLO CK s '
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OP HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
BITE EVALUATION AND SYSTEM SPECIFICATIONS
BENCHMARK /REFERENCE POINT LOCATIONS
ELEVATION OF PROPOSED SYSTEM SITE I8
SUBDIVISION:
AGENT: t—o D _ 67-e � et_ `
(Section /Township /Range /Parcel No. or Tax ID Nut
sNIBUSW== == =s ssssasaasssssasaseass sssssess sssssICs sssssssssss:s s =MUMUMM:OMUMOMsss:ssssss *sss
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENOINEER'8
PROVIDE REGISTRATION NUMBER AND 8ION AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE Q/) YES 4E0 NET USABLE AREA AVAILABLE: AC
TOTAL ESTIMATED SEWAGE FLOW: GALLONS PER DAY (RESIDENCES -TABLE 1 / OTHER -TABLE
AUTHORIZED SEWAOE FLOW: 34• OALLONS PER DAY (1500 OPD /ACRE OR 250 OPD/ CRE]
UNOBSTRUCTED AREA AVAILABLE: -s'/ SQFT UNOBSTRUCTED AREA REQUIRED: 5
(INCHES /FT] (ABOVE /BELOW] BENCHMARK /REFERENCE PO
THE MINIMUM BETBACKJCH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE
SURFACE WATER: FT DITCHES /SWALESz* -- -- FT NORMALLY WET? [ ] YES ril
WELLS: PUBLICS FT LIMITED USE: _ - PRIVATES FT NON - POTABLE: r-----
BUILDING FOUNDATIONS: S FT PROPERTY LINES: S FT POTABLE WATER LINER: /d
SITE SUBJECT TO FREQUENT FLOODING: ( ) YES ( NO 10 YEAR FLOODING?
10 YEAR FLOOD ELEVATION FOR SITE: L /NGVD SITE ELEVATION:
SOIL PROFILE INFORMATION SITE 1
]dunsell • /Color Depth
74,;;A. Ll t o ?.
(?- to
to
to
to
to
USDA SOIL SERIES:
to
to
to
L La�G
SITE EVALUATED
PERMIT # -! 3 "� - 20 4' '
SOIL PROFILE INFORMATION SITE 2
[ ) YES [T
. FT MSL /N
Munson #IColor Texture Depth
to
to
to
to
to=
to
to
to
to
USDA SOIL SERIES:
OBSERVED WATER TABLE: Ld INCHES [ABOVE / SE W] EXISTING GRADE. TYPES (PERCHED / APPARE1
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ) E STING ORA
BIOS WATER TABLE VEOETATION: ( ) YES ) ] NO MOTTLING: [ ) YES (4.41111 DEPTH:
SOIL TEXTURE /LOADING RATE FOR SYSTEM 8151NO: S DEPTH OF EXCAVATION: INC
DRAINFIELD CONFIGURATION: ( ) TRENCH (id BED ( ) OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:7.-
[X] Repair
APPLICANT:
LOT:
PROPERTY STREET ADDRESS:
PROPERTY ID #t
T
A
N
K
D
R
A
I
N
F
I
E
L
D
0
T
E
R
SYSTEM DESIGN AND SPECIFICATIONS
FILL REQUIRED:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
A OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, F8 & Chapter 10D -6, PAC.
CONSTRUCTION PERMIT FOR:
( ) New System ( ] Existing System
( ) Abandonment
— - ?
INCHES
Holding Tank
J
Other(Specify)
AGENT: yr)
sri o N 96 .rt.
BLOCK: SUBDIVISION:
( 01 SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ J SQUARE FEET SYSTEM
TYPE SYSTEM: ( ) STANDARD [ ) FILLED
CONFIGURATION: ( ) TRENCH [ 10 BED
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
TITLE:
NRS-N Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016.0)
[ ] MOUND [
PERMIT #
DATE PAID
PEE.PAID. $
RECEIPT 0
] Temporary /Experimenta
Roo v
EXCAVATION REQUIRED: [ ) INCHES
(SECTION/ TOWNSHIP /RANGE /PARCEL NUMB R]
(OR TAX ID NUMBER)
=:==a==ma=ss = = = = =_ _ = = = = =a== =====c=====_____ e= .= = = = = =__ = = = = =a= = = = = = =s = ==
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6, FA
REPAIR PERMITS AND HOLDINO TANK PERMITS EXPIRE 90 DAYS. FROM. THE DATE OF ISSUE. ALL OTHER PERMIT
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE S1 ISFACI'ORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS WHICE SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUC
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NUI, AND .VOID.
= = ==s= == == = =s == = = = = = = = = == ==s== =s == = = = = =_____________ = ====s= =cu=ss= = = = = = == = ==
(GALLONS / OPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI - CHAMBERED /IN SERIES:(
[GALLONS / OPD] 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: [
)
( ] (INCHES /FT) (ABOVE /BELOW] BENCHMARK /REFERENCE POIN1
] [INCHES /FT) (ABOVE /BELOW) BENCHMARK /REFERENCE POINT
T % 717. 0.0 et CPHU
EXPIRATION DATE: G V .-
Page 1 of 2
( Legal Description
p Owner's Address
pContracting Co.
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
a Job Address VS U L °l ( S�-
F 1-1 / /42-
Lessee / Tenant Ro \ r Master Permit #
cop C)(D - t
P i^ n�i-
Qualifier 1Mi c VNA
0�e\,, J Asst - - 0 Phone c / 4, 6 j
0 State # Municipal # 4 'Competency # 0 Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL LUMBING) MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION V'U
Square Ft. Estimated Cost(value)
Signature of owner and /or Condo President ' Signature of Contractor or
Date: Dat •
Notary as to Owner and /or Condo President Nolr,
My Commission Expires:
MY' 1101,
\ 1AYCOMMISOM EXPIRES an
;�i SSION NUMBER CC265
** * * * * * * * * * * *
FEES: PERMIT --V ®9 RADON C.C.F. ' NOTARY
APPROVED: Fire
Zoning Buildin
Mechanical Plumbin
Tax Folio '4 .JAG 4 e
Phone
ICY /5 SC c1(9 A uE
Address- 7 Ito LM ��c.,,.no .r
V%/
9 o o .oc
3 901
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.
3 -iV 97
er- Builder
IMINIAL. VAN CAMP
ARYPusuc
COMMI§S,QN EXMIt
TOTAL DUE 357
Other
Electrical
Engineering
1
' 1
1 ,
■ 1 1 ■ ,
I I
, .
, i I
— ; ■ ' • . 1
i i • , I
, , 1
, . ' , ; ' . ' ...4■44.w....',..r.. 1
, ....4....1........ .........r tif..7....1". --0 ....., - .. --ra...,!.. =.4.20.--r=r.temno,...............c.i.,.....,..............
■
. 4.. ......,, j....,...„.....
! J I
I 1 ■ 1 1 . ' 1 ' 1 ' ' . ' ■ I , i I i .
. ..
■ 1 L'
! '
1 1
, -,-- 1 1
■ 1 1 1 I ■ • I , , ! ' 1 i
i ' '' , • I "
I '
, - 1
I ,
, I
, , ••„
1 ; ;
1 1 1 1 1
11 11 ' 11 1 1 1 1,; ■1 I , 1 1,1,11 , 1 11 III , !
1 1 1 1 t ■ ' I I . 11 ' . 1 1 ' ' 1 ' 11 ' ' 1 I I
11 11 ' I I ! . , 11 i [ I i _1 I , 1 1 ' 1. ' ',. 1. 1 ;„ 1 , 1 I „1 , 1 1 I ' ' 11 ' ■ . , 1
Site Plan Submitted by:-;„
Plan Approved
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II SITE PLAN 73 73 t9"
, Z1 11 ,
1 1
•HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-002-4015-6)
4,
I 1 •
1 , I
C9•0
7 6 '
SIGNATURE
I . 1
Notes:
Not Approved Date
ALL CHANGES MUST BE APPROVED BY THE PUBLIC HEALTH UNIT
<7
Trrti
,2r
County Public Unit
Page 2 of 3
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[(° Repair [ ] Abandonment [ ] Other(Specify)
T o? ! e AGENT: / ro
APPLICANT:
PROPERTY STREET ADDRESS: P` /) A i E ,s±
J V �
LOT:
PROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
BLOCK: SUBDIVISION:
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. HRS 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
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
T [- ] [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 PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [
D [ 4 1 - 6 0 ] 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: /'•
] INCHES
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 - 0)
[ ] MOUND [ ]
[
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
TITLE: Y""` ; ti � 4 CPHU
4,- ]
APPLICANT
1
EXPIRATION DATE: A
Page 1 of 2
INSTRUCTIONS:
PERMIT NUMBEER: Permit tracking number assigned by CPHU.
APPLICATION FOR: Check type of permii, 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 represertstivr,.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY IDk: 27 character id number for property. (CPHU may require property appraiser ID # or section/township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 1OD-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 Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPHU.
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.
Installer
Applican i 1 P mit Nu 3 - 3'° �3
Q O !!
PART - SYS EM IN A TION INSPECTION AND FINAL INSTALLATION APPROVAL
Proper tank legend:
Other findings:
Inspected by:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND INSTALLATION PERMIT
2 / EA, .e. P, -i
Yes ✓ No
c
HRS —H Form 4016, Jan 86 (Replaces Feb 85 edition which may be used)
(Stock Number: 5744002 - 4016 -4)
Tank Manufacturer »/7
Tank material C 1 e/( Tank level: Yes 7` No
Tank size '� gallons gallons P1 & gallons
Tanks watertight: Yes v No
Proper tank outlet device: Yes ✓ No Manhole or marker to grade: Yes
Drainfield Trench
Length Width Length Width
feet feet l feet feet Length f--' feet x ---- feet= ft
/
feet feet {�I # feet feet Proper No. drainlines: Yes 1./ No (3(3-.) feet feet feet feet Proper pipe separation: Yes No
Total = ft /z Total = ft Distribution box level: Yes No '
/
Systems located as permitted: Yes v No
Systems including plumbing stub -outs installed at proper elevation: Yes No 4
Average depth to drainpipe invert from finished grade;? inches Maximum depth J- f Inches
Average depth of drainfield gravel /- inches Minimum depth of gravel /02 inches
Proper gravel size: Yes tr No Gravel is suitable quality Yes ✓ No
Backfill or fill material as required: (Quality) Yes / No (Quantity) Yes ✓ No
Absorption Bed
No
Length 10 feet x 3 2. feet = 3c0 ft2
�'. _._/ Date a' _ _
PART II ) FINA� STALLATION APPROVAL
Date Approved by:
AN APPROVED INSTAL I T • DOE NOT GUARANTEE PERFORMANCE
Note: Completed copies of this form b provided to he applicant, installer and the building department.
COUNTY P U r
HEALTH UNIT
Page 2 of 2