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—
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