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790 NE 96 St (10)Permit No. Amount of Permit $ !•' . ' ...4--_ ss. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether here,* specif ed or not. A copy of approved plans and specifications must be kept at building during progress of work rzi M Owner's Name and Address ` ( L� ' s�l A4 No Street e 1 "" t Registered Architect and /or Engin Employing Plumber's Name / 7 £T No. Location and Legal Description Lot Block Street and Number where work is to be performed —No. t_ State work to be performed and purpose of building (By Floors New Building Remodeling Addition Repairs )( Subdivision Size Septic Tank Type of Tank Capacity Gals. Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well . Size of Soakage Pit (Signed) ? _ :er ( Signed ) Date Street No. of Stories g In spector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations�s an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supp ement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ Only such sub- contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. Master Plumber. STATE OF FLORIDA, COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY Tues URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT' NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONTR. LIST ;) ��1� „V C ECK r 71/ Permit No. Amount of Permit $ !•' . ' ...4--_ ss. MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether here,* specif ed or not. A copy of approved plans and specifications must be kept at building during progress of work rzi M Owner's Name and Address ` ( L� ' s�l A4 No Street e 1 "" t Registered Architect and /or Engin Employing Plumber's Name / 7 £T No. Location and Legal Description Lot Block Street and Number where work is to be performed —No. t_ State work to be performed and purpose of building (By Floors New Building Remodeling Addition Repairs )( Subdivision Size Septic Tank Type of Tank Capacity Gals. Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well Nature of Water Supply: City —Well . Size of Soakage Pit (Signed) ? _ :er ( Signed ) Date Street No. of Stories g In spector. The undersigned applicant for this building permit does hereby certify that he understands and accepts his obligations�s an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supp ement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The undersigned agrees to employ Only such sub- contractors, on work to be performed under this permit, as are licensed by Miami Shores Village. Master Plumber. STATE OF FLORIDA, COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts therein by him stated are true. My Commission Expires Notary Public, State of Florida NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. Permit No. Location and Legal Description Lot_ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether heir specified or not.,A, copy of approved plans and specifications must be kept at building during progress of work.. f i Owner's Name and Address ;– ►� � ` o — ______. Street Registered Architect and /or Engineer t Employing Plumber's Name � Block Street and Number where work is to be performed —No 1 1 _ State work to be performed and purpose of building (By Floors) New Remodeling Addition_ Size Septic Tank .- I) Type of Tank Feet of Drain Nature of Water Supply: City Well Amount of Permit S __ 1 � t' _ ' ' t� The undersigned applicant for this building permit does hereby ce under the Florida Workmen's Compensation Act, being Section 5966, plied with the provisions thereof, and will require similar compliance performed under this permit; and will post or cause to be posted for required by the Act. The under signed agrees to employ only such licensed by Miami Shores Village. STATE OF FLORIDA, } COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly ss. My Commission Expires _____ Dist. Feet of Tank or Drain Field from Well Date i✓ rte'' -- - i` ma- Street SubdivisioII –JG �� ^" +jti Repairs No. of .Size of Soakage Pit rtify that (Signed) 4. appeared �--- .�_ - - -- to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the . of the above described construction, that he has carefully read the therein by him stated are true. • Capacity • 1 £ d Notary Public. State of Florida r (Signed) +x–�' l - – / Plumbing Inspector. understands and accepts his obligations as an employer of labor Compiled General Laws of Florida Permanent Supplement, and has com- from all contractors or sub-contractors employed by him in the work to be inspection on the site of the work such public notice or notices as are sub - contractors, on work to be performed under this permit, as are Master Plumber. - - - - authorized to administer oaths and take acknowledgments, perionally foregoing application, and that he did sign the same, and that all facts NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or racy materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY TUBS URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT'NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC SEWER TANK CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONTR. LIST CHECK j jo/ Permit No. Location and Legal Description Lot_ MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with, whether heir specified or not.,A, copy of approved plans and specifications must be kept at building during progress of work.. f i Owner's Name and Address ;– ►� � ` o — ______. Street Registered Architect and /or Engineer t Employing Plumber's Name � Block Street and Number where work is to be performed —No 1 1 _ State work to be performed and purpose of building (By Floors) New Remodeling Addition_ Size Septic Tank .- I) Type of Tank Feet of Drain Nature of Water Supply: City Well Amount of Permit S __ 1 � t' _ ' ' t� The undersigned applicant for this building permit does hereby ce under the Florida Workmen's Compensation Act, being Section 5966, plied with the provisions thereof, and will require similar compliance performed under this permit; and will post or cause to be posted for required by the Act. The under signed agrees to employ only such licensed by Miami Shores Village. STATE OF FLORIDA, } COUNTY OF DADE. Before me, the undersigned authority, a notary public, duly ss. My Commission Expires _____ Dist. Feet of Tank or Drain Field from Well Date i✓ rte'' -- - i` ma- Street SubdivisioII –JG �� ^" +jti Repairs No. of .Size of Soakage Pit rtify that (Signed) 4. appeared �--- .�_ - - -- to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the . of the above described construction, that he has carefully read the therein by him stated are true. • Capacity • 1 £ d Notary Public. State of Florida r (Signed) +x–�' l - – / Plumbing Inspector. understands and accepts his obligations as an employer of labor Compiled General Laws of Florida Permanent Supplement, and has com- from all contractors or sub-contractors employed by him in the work to be inspection on the site of the work such public notice or notices as are sub - contractors, on work to be performed under this permit, as are Master Plumber. - - - - authorized to administer oaths and take acknowledgments, perionally foregoing application, and that he did sign the same, and that all facts NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or racy materials and /or workmanship. Permit No 40 • MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida. and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with whether he ed or not. copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address ___ Registered Architect and /or Enginee Employing Plumber's Name r1 _/ No. >L CQa.._ Street____--__________ _ Location and Legal Description Lot__ . _____ __ _�____- Blo _ ��__ Subdivision _j.__. _ L Street and Number where work is to be performed —No l - tl- ____ / ____ __ I Street ..... _-__-__-_ State work to be performed and purpose of building (By Floors) New Building_ Remodeling Addition Repairs No. of Stories___— Size Septic Tank d D Feet of Drain Tile___________ Nature of Water Supply: City LWell . Amount of Permit S / � O 0 Type of Tank ___ Dist. Feet of Tank or Drain Field from Well .Size of Soakage Pit (Signed) Street.. _Capacity Gals V Q appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the . of the above described construction, that be has carefully read the foregoing application, and that he did sign the same, therein by him stated are true. My Commission Expires Notary Public. State of Florida /C Plumbing Inspector. y The undersigned applicant for this building permit does hereby certify that understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The under signed agrees to employ only such sub - contractors, on work to be performed under this permit, m are licensed by Miami Shores Village. (Signed) ko) . )1 1 Master Plumber. STATE OF FLORIDA, COUNTY OF DADE. m. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally and that all facts NOTE: A re- inspection fee of $1.00 will be made when such re - inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. CLOSETS BATH TUBS SHOWERS LAVA- TORIES SINKS SLOP SINKS LAUNDRY Tuns URINALS CATCH BASIN FLOOR DRAIN DRINKING FOUNT' NS TOTAL FIXTURES CONTR. LIST CHECK SEPTIC TANK SEWER CONN. DRAIN FIELD SOAKAGE PIT GREASE TRAP SOLAR HEATER DEEP WELL SPRKLR. SYSTEM SWIM'G POOL CONTR. LIST CHECK Permit No 40 • MIAMI SHORES VILLAGE PLUMBING INSPECTION DEPARTMENT APPLICATION FOR PLUMBING PERMIT Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida. and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division of Miami Shores Village shall be complied with whether he ed or not. copy of approved plans and specifications must be kept at building during progress of work. Owner's Name and Address ___ Registered Architect and /or Enginee Employing Plumber's Name r1 _/ No. >L CQa.._ Street____--__________ _ Location and Legal Description Lot__ . _____ __ _�____- Blo _ ��__ Subdivision _j.__. _ L Street and Number where work is to be performed —No l - tl- ____ / ____ __ I Street ..... _-__-__-_ State work to be performed and purpose of building (By Floors) New Building_ Remodeling Addition Repairs No. of Stories___— Size Septic Tank d D Feet of Drain Tile___________ Nature of Water Supply: City LWell . Amount of Permit S / � O 0 Type of Tank ___ Dist. Feet of Tank or Drain Field from Well .Size of Soakage Pit (Signed) Street.. _Capacity Gals V Q appeared to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the . of the above described construction, that be has carefully read the foregoing application, and that he did sign the same, therein by him stated are true. My Commission Expires Notary Public. State of Florida /C Plumbing Inspector. y The undersigned applicant for this building permit does hereby certify that understands and accepts his obligations as an employer of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com- plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are required by the Act. The under signed agrees to employ only such sub - contractors, on work to be performed under this permit, m are licensed by Miami Shores Village. (Signed) ko) . )1 1 Master Plumber. STATE OF FLORIDA, COUNTY OF DADE. m. Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally and that all facts NOTE: A re- inspection fee of $1.00 will be made when such re - inspection is made necessary by improper notice for inspection, or faulty materials and /or workmanship. Date L. "' - ' Job Address /' Legal Description 1 / Owner / Lessee Owner's Address Contracting Co. 71 . ' / Qualifier " . Square Ft. APPROVED: PERMIT APPLICATION FOR MIAMI SHORES VILLAGE / Tenant .. `1" State # Municipal # Competency # Ins.Co. Architect /Engineer Address Bonding Company Address Mortgagor Address Permit Type(circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN WORK DESCRIPTION /'/ '` ^ WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAILURE TO DO SO MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT). Application is hereby made to obtain a permit to do work and installation as indicated above, and on the attached addendum (if applicable). I certify that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that separate permits are required for ELECTRICAL, PLUMBING, SIGNS, POOLS, ROOFING and MECHANICAL WORK. OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated--; > Signature of owner and /or Condo President Date: Notary as to Owner and /2r Condo President My C ire&:.,,, '"'"""' ew.o 4�S`$'1A�. ^ P.i OARC;E , . _ .. 1995 -. L ATiS ** * * *, * * * FEES: PERMIT 1 RADON C.C.F. I..4° Zoning Mechanical SS# : Fire Buildin Plumbin it ' -/ ' Phone Estimated Cost(value) /- 6 Master Permit # $ fl7. Phone Addresst%1 Tax Folio 1) 1°2 'd »i O0J0 S Other NOTARY i of Contractor or Offer der to Contractor or Owner- Builder my Etm0 PAO /• F 7 -96 te4tifit-0 OY WW1 NS CO : cON7708 * * ** TOTAL DUE J )" b 6 Electrical `Efigineering CONSTRUCTION PERMIT FOR: [ ] New System [ ] Existing System [ t4 Repair [ ] Abandonment APPLICANT: PROPERTY STREET ADDRESS: LOT: PROPERTY ID #: 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 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 T [ A [ N [ K [ D [ ) ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [ } BED [ ] N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ ] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT L D FILL REQUIRED: [ ] INCHES 0 T H E R SPECIFICATIONS BY: TITLE: APPROVED BY: ., STATE OF FLORIDA PERMIT # DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID $ CONSTRUCTION PERMIT RECEIPT # Authority: Chapter 381, FS & Chapter 10D -6, FAC , " 7 BLOCK: SUBDIVISION: ] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ] ] [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: [ ] DATE ISSUED: EXPIRATION DATE: AGENT: l HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744 - 001 - 4016 - 0) [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER] [OR TAX ID NUMBER] EXCAVATION REQUIRED: [ ] INCHES TITLE: �t r/ e-"' - 41 /7 d [ ] Holding Tank [ ] Temporary /Experimental [ ] Other(Specify) CPHU Page 1 of 2 INSTRUCTIONS: PERMIT' NUMBER: Permit tracking number assigned by CPHU. APPLICATION FOR: Check type of permit, 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 representative. MAILING ADDRESS: P.O. box or street mailing address for applicant or agent. LOT, BLOCK, SUBDIVISION or PROPERTY ID#: 27 character id number for property. (CPHU may require property appraiser ID 8 or section/township /range /parcel number) SYSTEM DESIGN AND SPECIFICATIONS: TANK: Minimum specifications from Chapter 1OD-6, FAC. DRAINFIELD: Minimum specifications from Chapter IOD -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. 111111111111MORMINII EMU 111 1111111110111111111111111 NS VI felt RN H NM •111111 11111 MOM •th 3 :411;11= 400 alIKWIFTATWO17111, M,110 1r 4 1 ' STATE OF FLORIDA - DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PE Permit Application Number • ' • Notes - 40 A6 96 57— Site Plan Submitted by Plan Approved By HRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used) ck Number 5744-002-4015-6) -PART II SITE PLAN fir D - • - • Not Approved 11-4W- 141 County Public Unit ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT -40-0-q=1107ZW OE: . ",/ • -e-r" in I Date C" Page 2 of 3 APPLICATION FOR: [ ] New System [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental [X_] Repair [ ] Abandonment [ ] Other(Specify) APPLICANT: AGENT: pro 601 t MAILING ADDRESS: / - /s 9 6 TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6,1 FLORIDA ADMINISTRATIVE CODE. PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED] LOT: PROPERTY ID #: PROPERTY SIZE: BLOCK: PROPERTY STREET ADDRESS: DIRECTIONS TO PROPERTY: BUILDING INFORMATION Unit Type of No Establishment 1 2 3 4 STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES • ONSITE SEWAGE DISPOSAL SYSTEM APPLICATION FOR CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC SUBDIVISION: ACRES [Sqft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [ ] PUBLIC [ ] Garbage Grinders /Disposals [ ] Ultra -low Volume Flush Toilets DATE OF SUBDIVISION: [Section /Township /Range /Parcel No.] ZONING: r) X ei4 5 7` [ ] RESIDENTIAL [ ] COMMERCIAL No. of Building # Persons Bedrooms Area Soft Served ] Spas /Hot Tubs HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4015-1) PERMIT # DATE PAID FEE PAID RECEIPT # 3 % 9 3 -l0 $ y,,a TELEPHONE: 9 A - 6 S 3 3d 1 Business Activity For Commercial Only [ ] Floor /Equipment Drains 1 Other (Specify) DATE: / / 3— Page 1 of 3 APPLICANT: /- U LOT: PROPERTY ID #: STATE OF FLORIDA ° DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS BLOCK: SUBDIVISION: PERMIT # 7.5 7C AGENT: pr i2 O a 7` / [Section /Township /Range /Parcel No. or Tax ID Number TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUS PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [}i] NO NET USABLE AREA AVAILABLE: ACRE TOTAL ESTIMATED SEWAGE FLOW: ,a ()G) GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2 AUTHORIZED SEWAGE FLOW: C GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] UNOBSTRUCTED AREA AVAILABLE: G SQFT UNOBSTRUCTED AREA REQUIRED: Y g Q SQF BENCHMARK /REFERENCE POINT LOCATION: ELEVATION OF PROPOSED SYSTEM SITE IS 1--- - [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POIN THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES: SURFACE WATER: A FT DITCHES /SWALES: ,( A- FT NORMALLY WET? [ ] YES [-(J N WELLS: PUBLIC: A,,4, FT LIMITED USE: FT PRIVATE: /V / fr FT NON- POTABLE• /V//, F BUILDING FOUNDATIONS: S FT PROPERTY LINES: < FT POTABLE WATER LINES: 76 F SITE SUBJECT TO FREQUENT FLOODING: [ ] YES NO 10 YEAR FLOODING? [ ] YES N 10 YEAR FLOOD ELEVATION FOR SITE: _ FT NGVD SITE ELEVATION: FT MSL/RGV SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2 Munsell # /Color Texture USDA SOIL SERIES: Depth ,- to /2 to to to to to to to OBSERVED WATER TABLE: 6 -0 INCHES [ABOVE / ESTIMATED WET SEASON - WATER TABLE ELEVATION: HIGH WATER TABLE VEGETATION: [ ] YES [,1 NO SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 003-4015 -1) Munsell # /Color Texture USDA SOIL SERIES: Y] DRAINFIELD CONFIGURATION: [ ] TRENCH [ BED [ ] OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: Depth to to to to to to to to to BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT] INCHES [ ABOVE / BELOW ] EXISTING GRADE. MOTTLING: [ ] YES NO DEPTH: INCHES (, S DEPTH OF EXCAVATION: 2 V INCHE! SITE EVALUATED BY f - 1 • -� ' / DATE: d/2— Page 3 of 3