DRAINFIELD REPAIRCONSTRUCTION PERMIT FOR:
((� New System [ J ] Existing System
[ X ] Repair [ W ] Abandonment
APPLICANT:
PROPERTY STREET ADDRESS:
LOT:
T
A
N
K
D
R
A
I
F
E
L
D
0
T
E
R
2Z
FILL REQUIRED:
APPROVED BY:
DATE ISSUED: LI
STATE OF FLORIDA {
1
DEPARTMENT OF HEALTH s
ONSITE SEWAGE DISPOSAL SYSTEMS
CONSTRUCTION PERMIT
Authority: Chapter.381, FS & Chapter 10D -6, FAC
BLOCK:
SPECIFICATIONS BY: I
[SECTION /T0WMSEIP /RANGE /PARCEL NUMBER"-
(OR TAX ID NUMBER]
ass^ smaaaaoa
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -(
TAC. °:REPAIR PERMITS' AND'HOLDING•TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHI
PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. DEPARTMENT OF HEALTH APPROVAL OF SYSTEM DOI
NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERII
FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT REQUIRE THE APPLICANT TO MODIFY TI
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
PROPERTY ID : 1, Z Q c_ 0/4- 26 f
'� l 0
SYSTEM DESIGN AND SPECIFICATIONS ) j
(78- ] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:(
( M ] (GALLONS / GPD) CAPACITY MULTI- CHAMBERED /IN SERIES*(
[ ] GALLONS GREASE INTERCEPTOR CAPACITY (MAXIMUM CAPACITY SINGLE TANK: 1250 GALLON:
[ ] GALLONS PER DOSE DOSING TANK CAPACITY 03SEKATE [ . ] PER 26_ -HRS NO. OF PUMPS:
( d ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ,. ] SQUARE FEET / SYSTEM
TYPE SYSTEM: [ ] STANDARD
CONFIGURATION: ( ] TRENCH
LOCATION OF BENCHMARK: )(.
ELEVATION OF PROPOSED SYSTEM
BOTTOM OF DRAINFIELD TO BE [
INCHES
SUBDIVISION:
DH 4016, 10198 (Replaces HRS -H Form 4016 (page 1) which may be used)
(h Holding Tank (1 Temporary /Experimental
(1-6 Other(Specify)
AGENT:
[y FILLED
( ] BED
t
IHIS?tk,1Vtat is OT FGI.A D V I
PERMIT # 6 R-3 `t i 7
DATE PAID /1-
FEE PAID $ ' ,C . d c�
RECEIPT # Q.. / e a (
i t.:It % _ ... s
�
DO — TOM or GRAu �'t ELEVATION , _ a
1T!~R OF E ( ' N , .
y1,1 ST a WIDER It ` t 1 , ,ra
■■
.� . s . .vr sfi- ,--
iir. f TYTLE: 19 '
331,36
] MOUND ( ] -
GO' 0, :. 'jr E
SITE (z4 (INCHES /FT] [ABOVE /BELOW BENCHMARK /REFERENCE POI!
sq. o ] [INCHES /FT] (ABOVE /BELOW] BENCHMARK /REFERENCE POI1
EXCAVATION REQUIRED: ( 2 ] INCHES
P iZ a Off' SUG }WU Y F 1 MYf" FD gri!
U34NDER warrnm OF fRA NFIELC
/A m)) LI A' CH
ZEPIRATION DATE: 1
Page 1 (DO
i
Notes:
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT,'/ I.
Permit Application Number t/ +3 1
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
"75.00
zee_ ,AA:eli 1 .2/ 4/
Site Plan submitted by: \ lr,
Plan Approved A ,
Sig atu
Not Approved
{ A d
f
ALL CHANGES MUST BE a! PPROVED BY THE COUNTY HEALTH DEPARTMENT
f /(J( Mr Cam rVIcT
C �c ^,5;7L iitte
Date !I 7/4 .3
County Health Departmei
APPLICANT: ( /
LJ A Al e 5 &f<11/ A GENT : 8 Z 1 2 Ar ;✓ �r } {6 2r 49 I
LOT: 2a¢ 3 3 BLOCK: z3 SUBDIVISION: 01 fl 1 ,17. CfCc_ . 110. :3
OPERTY ID /J: [Section /Township /Range /Parcel No. or Tara ID Number
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM;[
SITE EVALUATION AND SYSTEM SPECIFICATIONS
TAO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSQN...- ENGINEER'S MUS
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: 1] YES [ ] NO NET USABLE AREA AVAILABLE: 0/7 ACRE
TOTAL ESTIMATED SEWAGE FLOW: 7vv GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2
AUTHORIZED SEWAGE FLOW: 6,p Q GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: ( .C>0 SQFT UNOBSTRUCTED AREA REQUIRED: a Orr SQF
BENCHMARK/ REFERENCE POINT LOCATION: //c, ` _ F p j �He r p. l 4 11, ) J ,
ELEVATION OF PROPOSED SYSTEM SITE IS A. INCHES FT] [ABOVECOLO BENCHMARK /REFERENCE POIN
THE MINIMUM SETBA WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: q/ A- FT DITCHES /SWALES: /!'/ FT NORMALLY WET? [ ] YESA4 [ ] N
WELLS: PUBLIC: A/ FT LIMITED USE: A/4 FT PRIVATE: N:i FT NON- POTABLE: 5 0 F
BUILDING FOUNDATI NS:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [lX
10 YEAR FLOOD ELEVATION FOR SITE: l
SOIL PROFILE INFORMATION SITE 1 ;,Aa ,T
Munsell Color
/0 1 1
USDA SOIL SERIES:
Texture Depth
LO Am 0" to
to !a rr—
�',� ai6 /0 " to
Art) to
1 r to
to
// to
1/
to
to 'n
'i I f/ 4-AA/.pi
OBSERVED WATER TABLE: A/4 INCHES (ABOVE /
ESTIMATED WET SEASON WATER TABLE ELEVATI
HIGH WATER TABLE VEGETATION: [ ] YES [!7'] NO
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING/
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ]
REMARKS /ADDITIONAL CRITERIA:
OH 4015. 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used)
(Stock Number: 5744- 003 - 4015 -1)
FT PROPERTY LINES: a FT POTABLE WATER LINES: /0.0 F
0
10 YEAR FLOODING? [ J YE_S �] N.
NGVD SITE ELEVATION: 1 T_MS NGV
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture
/ /R, 5/1 Lo A wv v
F"qtav ,<14110)
..emu
) �
1
1'
}/
USDA SOIL SERIES:
SITE EVALUATED BY: ■ r P SSU'v / Pipe//. fLdi b 1i
PERMIT #
r•
t. P k?, tr `t /
Depth
0 '/ to
to 1i"
" to
to
to
to
to
to
I) to '
BELOW] EXISTING GRADE. TYPE: PERCHED / APPARENT:
7 Ps INCHES [ ABOVE / / BELO J EXISTII1jG GRADE.
MOTTLING: [ ] YES [V] NO DEPTH: POI INCHE:
7 .) '
DEPTH OF EXCAVATION: INCHE:
BED [ ] OTHER (SPECIFY)
C DATE: l / A i 10
.
Page 3 of
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 11/20/2003
Applicant: JAMES
Owner: MERRY
JOB ADDRESS: 879
Contractor PIPELINE PLUMBING INC
Local Phone: 954 680 - 4415
Parcel # 1132060142640
Signed:
NE 97
(INSPECTOR)
Plumbing Permit
Permit Number: PL2003 -307
MERRY
JAMES
ST
Fees:
FEE2003 -7337
FEE2003 -7338
FEE2003 -7339
FEE2003 -7340
FEE2003 -7341
FEE2003 -7342
FEE2003 -7343
Description
Building Fee
CCF
Scanning Fee
Training and Education Fee
Technology Fee
Builders Bond
Notary Fee
Total Fees:
Amount
$175.00
$1.80
$3.00
$0.60
$4.37
$300.00
$5.00
$489.77
Total Fees: $489.77
Total Receipts: $0.00
m 1 8 PAio
Permit Status: APPROVED Permit Expiration: 5/16/2004 Construction Value: $2,400.00
Work: DRAINFIELD REPAIR
In consideration of the issuance to me of this permit, 1 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 responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder)
Contractor's Address: DOING BUS IN DADE CO
Page 1 of 1
Legal Description: MIAMI SHORES SEC 3 PB 10 -37 LOT 22 & W1/2 OF LOT 23
BY:
BLK 73
APPLICANT:� .� � , ; _ -
AGENT .' �.- 1 � ' .r
.
PROPERTY ADDRESS:
LOT: �) BLOCK: 7 ,, SUBDIVISION: ;le _r ;
=======MMIM========
TANK INSTALLATION
[01) TANK SIZE (10:5'0 [2]
[02 ] TANK MATERIAL
[ 0 3] OUTLET DEVICE
[6t] MULTI- CHAMBERED [ Y / �)
[ OUTLET FILTER
(06) LEGEND ./'' /
l
1
1
l
1
1
1
1
1
l
l
1
1
]
l
i
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM[
CONSTRUCTION INSPECTION AND FINAL APPROVAL
[07] WATERTIGHT
(08) LEVEL/(/„,
[09 ] DEPTH TO LID
DRAINFIELD INSTALLATION
(10] AREA [1] j -: )(.2 (j42] SIFT
[11] DISTRIBUTION BOX 91 iEiDER r9 d
[12] NUMBER OF DRAIMLINES
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
(15] DEPTH OF COVER/
[16] ELEVATION [ABOVE/BBL BM [
[17] SYSTEM LOCATION l [
[18] DOSING PUMPS Ai 1,/
(19] AGGREGATE SIZE
(20] AGGREGATE EXCE88IVE FINES s [
[21] AGGREGATE DEPTH 0 (
FILL / EXCAVATION MATERIAL
(22] FILL AMOUNT /_,
(23] FILL TEXTURE
(24] EXCAVATION DEPTH
(25] AREA REPLACED
(26] REPLACEMENT MATERIAL
/ ,
EXPLANATION OF VIOLATIONS / REMARKS:
ti
DH 4016, 10/97 (Previous Editions May Be Used)
PROPERTY ID 1:
PERMIT NO.:'
DATE PAID: -
FEE PAID:
RECEIPT 1:
CHECKED (X] ITEMS ARE.NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
FINAL SYSTEM( [APPROVED /DISAPPROVED] Y(_
Ihrnstaliler / Contractor
s=a - -x=
SETBACKS
(27] SURFACE WATER o,C FT
(28] DITCHES , ' FT
[29] PRIVATE WELLS FT
[30] PUBLIC WELLS r FT
r 31 1 IRRIGATION WELLS .. FT
[32] POTABLE WATER LINES V s ;
(33] BUILDING FOUNDATION FT
(34) PROPERTY LINES FT
(35] OTHER FT
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] FINAL SITE GRADING
(47] CONTRACTOR
(48 ] OTBER
ABANDONMENT
[49] TANK PUMPED
[50] TANK CRUSHED & FILLED /.
1
1
1
1
CONSTRUCTION ..APPROVED) DISAPPROVED) ,.1 A.- ! .��, __a ° i ._. CND DATE:
(�
CHD DATE: --=- -T
Page 2 of 3
PERMIT NUMBER:
PPLICANT:
AGENT:
MAILING ADDRESS:
LOT, BLOCK, SUBDIVISION
PROPERTY
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model)
LEGEND (manufacturer code)
DRAINFIEL!P AREA (square feet)
DISTRIBUTION BOX / HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in ft)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS:
CONSTRUCTION APPROVAL:
[ +] SHOT
H.I.
ELEVATION
0
EXISTING GROUND
H.I.
[ -] SHOT
Permit tracking number assigned by CHD.
r•
Property owners full name.
Property owner's legally authorized representative.
P. • . Lox or street mailing address for applicant or agent.
Lot, Block and Subdivision for lot or
V character number for property. (property appraiser D # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFO °'MATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
Record item number, explanation of violation, and required
Cirde approded or disapproved, CHD signature and date.
FINAL APPROVAL: Cirde approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted unit the CHD has confirmed that'building construction and lot grading are in substantial
compliance with plans and specifications submitted with the pent application.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
AS BUILT INSTALLATION SKETCH
TOP OF AGGREGATE
H.I.
[ -] SHOT
H.I.
[ -] SHOT
M