35058Square Ft.
No ry a< to Owner and /o
My Commission Expires:
APPROVED:
Zoning
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date 10 1(0147 Job Address (0Z Ai& 9 l� Tax Folio `/ 1 I� 1/1 / 7/�
Legal Description tie � 1 ggie/
Owner / Lessee / Tenant fThfkrik% \r1 1 '( Ar water Permit 0 3- 50 . 317
Owner's Address 4iO //�� j � s�
�/ Phone /�.7 " 9- 1
-
Contracting Co. - h�' Address �� � �
Qualifier C), inALON SS# - - Phone 44_ f/
State # Municipal #
Architect /Engineer
Bonding Company
Mortgagor
Permit Type(circle one): BUILDING
WORK DESCRIPTION
WARNING TO OWNER: YOU MUST
SO MAY RESULT IN YOUR PAYING
TO OBTAIN FINANCING, CONSULT
NOTICE OF COMMENCEMENT).
Application is hereby made to obt
on the attached addendum (if appl
standards of all laws regulating
permits are required for ELECTRICAL
OWNER'S AFFIDAVIT: I certify that
be done in compliance with all app
authorize, the above -n
Signaturys owner and /or
Date: 401//0
sident
SEPHINE CHURCH
sk Flores
'��'doi L �o;:•' CC197545
*
FEES: PERMIT JAW RADON
Competency # Ins.Co.
Address
Address
Address
ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
1J
Estimated Cost(value) 1 oo
ECORD A NOTICE OF COMMENCEMENT AND YOUR
ICE FOR IMPROVEMENTS TO YOUR PROPERTY (
WITH YOUR LENDER OR AN ATTORNEY BEFORE R
in a permit to do work and - installation as indicated above, and
cable). I certify that all work will be perfo d to meet the
onstruction in this jurisdiction. I understan that separate
, PLUMBING, SIGNS, POOLS, ROOFING and MECHANI WORK.
all the foregoing information is accurate and tht all work will
icable laws regulating construction and zoning. Furthermore, I
or to do the work stated.
*
Date:
*
Mechanical
Buildin
/go
Signature of ntractor or Ca -
�o
Notary as to! • nfactir - or
My Commission Expires:;,. VY
C_ e al l6, 994
Bonded TiN Mr/ Fain. uuancs 1
NOTAR �U TOTAL D
AILURE TO DO
F YOU INTEND
CORDING YOUR
r- Builder
*
**
o
Fire Other
Electrical
Engineering I
ATE OF FLORIDA °ii PERMIT
pARzetrit OF HE4TR AND REHABILITATIVE SERVICES DATE PAID
'(iNSITE SEWAGE DISPOSRI+_ SYSTEN. .. PAID $
CONSTRUCTION PERMIT , .
BECEIPT #
Authority: Chapt r 381, FS & Chapter 10D-6, iFA
Oth,Q Sp.R,fy)
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System
Repair [ 7 Abandonn ►en
a
APPLICANT:
PROPERTY STREET ADDRESS :,
LOT: li a r _ , BLOCK :' iSBDIVISION;
PROPERTY ID #
BYSTEM.MUST BE- CONSTRUCTED IN ACC WITH SPECIFICATIONS AND OF CHANTER 1O 6
REPAIR HOLDING' TANK, P EXPIRE 90 DAYS FROM THE DATE OF ISSUE. OTHER PERMITS
R FROM TEE DATE OF : HIE N
S SUE. HRS'APPROVAL OF SYSTEM #S OT :GUARAN SATISFAC
PERFORMANCE FOR ANY ;SP.,ECIFIC _FERI OF TLME� ANY CHANGE IN MATERIAL FACTS ,WHIG$ NERVED AS A
iAsTs. FOR LANCE OF : THIS PERMIT REQUIRE. 1IIE. APPLICANT TO MODIFY THE PERMIT APP! SUCH
MAIL RESULT_ IN. T I.s PER I 't? $EINQ MA_ DH NULL AND VOID
-= 4 _ - = = - :- :
SYSTEM DESIGN AND SPECIFICATIONS
N
K
D
R
A
i
N
F
I
E
L
D
0
H
T
A [
[
[
[GALLONS" GPD] SEPTIC TAME/AEROBIC UNIT CAPACtTY MULTI -CHAMBE IN SERIES:'[ ]
CAPAC MULTI ` CHAMBERS / S [' ]
j OALLONS GREAS I NTECEPTOR 'CAPACITY (MAXIMUM CAPACI S INGLE- TANK: °'1250 GALLONS]
] GALLONS PER DOSE .DOBING:TANK CAPACITY DOSE RATE f.1. 24 HRS >.NO. OF PUMPS :
[ ) SQUARE
[ SQUARE
TYPE SYSTEM:
CONFIGURATION:
FILL REQUIRED: [ - -`'] INCHES
4
[ SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[ GR TAX ID NUMBER]
FEET PRIMARY D AINFIELD,SYSTEM ..
FEET SYSTEM
ST2NDARD [ _] FILLED
1 TRENCH [ 4.4
LOCATION OF BENCHMARK
ELEVATION OF PROPOSED SYSTEM S TE [ [INCHES /FT] [ABOVE /BELOW] BENCHMARK /DEFERENCE POINT
BOTTOM OF DRAINFIEI,D TO'BE.[ � ] [INCHES /FT].[ABOVE /BELOW] BENCHMARK /REFERENCE POINT
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
EXCAVATION REQUIRED:
TITLE;
HRS -H Form 4016, Mar 92 (0bso4etes previous ed {tions which may not be. used)
(Stock Number: 5744- 001 - 4016 -0) r
{C.
INCHES
INSTALLER/CONTRACTOR
1NSTRUCI`IONS:
PERMIT NUMBER:
APPLICATION FOR: Check type of permit, if Other specify type in blank.
ii
APPLICANT: Property owner's full name.
TELEPHONE:
AGENT:
MAILING ADDRESS:
LOT,' BLOCK, SUBDIVISION or
PROPERTY ID# 27 character id number for property. (CPHItJ may require property appraiser ID d or section /township /range /parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
DRATNFIELD:
OTHER:.
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:,
EXPIRATION DATE:
Permit tracking number assigned by CPHU.
Telephone number for applicant or agent.
Property owner's legally authorized representative.
P.O. box or street mailing address for applicant or agent.
Minimum specifications from Chapter 10D-6, FAC.
Minimum specifications from Chapter 10D-6, FAC.
Other specifications, such as operating permit requirements, loco - volume fdu:h toilets, variance provisos.
Name of individual providing specifications. If designed by a registered engineer must Ise seated.
County Public Health Unit (CPHU) personnel reviewing and approving permit.
Date permit is issued by CPHU.
One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the date'
issued.
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SIGNATURE
No
BE APPROVED BY
1
r
pD
TN UNIT
osisnaststiOnmeme
5 5 7 25 2 .5 . 4575 7
County. Public Unit
is
NotesJdd9 °
Site Plan Submi
Plan Approved
By /
jR3 H Form 4016, Feb 86'( Obaolei
(Stock Number: 6744- 002 - 4016 -6
DEPARTMENT
' tk?-LICATION FOR ON
ALL CHAt4GES MU
be
- STATE OF FLORIDA.
OF HEALTH AND REt1ABLITATIi/ 'SERVICES
1T -SEwAGE DISPOSAL ,SYSTEM CON TRUC // TI }} ON PERMIT
Permit Applicatir�n Nurhber
,
)
II SITE PLAN- s-=--- ---- --
onTLE .' f
D ate t''10 -
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