842 NE 96 St (3)SEPTIC TANK AND DRAINAGE INSTALLATIONS -
i t A. ceptic'rank
1123 EAST 23rd STREET
HIALEAH P. O. BOX 1012 FLORIDA
Phones: 88 -1114 - 88 -4955
Nights 3 -4775
Terms: Net — No discount
kt-0_ c y‘ze
Ac tierri/e_el
&c.ciAj d-wt
REPAIRS - CLEANINGS
eXS—Y V
COMMERCIAL DRAINAGE
SYSTEMS INSTALLED
AND MAINTAINED
CONCRETE GARBAGE
RECEPTACLES
UNDER GROUND, ABOVE
GROUND
CONCRETE CLOTHES POLES
/10,2_R
• Miami Shores Village
Building Department
Total Fee Now Due $
(Continued on opposite side)
BUILDING
PERMIT APPLICATION
FBC 2001
qn n`t 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit Type (circle): Building Electrical
Contractor's Company Name A aor‘eXi Coe
Contractor's Address nor
City M w.1 State FL Zip '33iG
Qualifier WOO et cur or
$ Value of Work For this Permit 2i tt'0
461
Permit No 0
- "` b
Master Permit No.
Owner's Name (Fee Simple Titleholder) Cil i (■+o r> Staples
Owner's Address 842 1\16
City N1SV1OreS State FL. Zip 331
Tenant/Lessee Name c2`"'-e-) Phone #
Phone #
Job Address (where the work is being done) 1342 NE q Co 5
City Miami Shores Village County Miami -Dade Zip 331 34:
Is Building Historically Designated YES NO ✓
Phone # c S 0 q
�R
Architect/Engineer's Name (if applicable) Phone #
Square Footage Of Work
Type of Work: ❑Addition ❑Alteration ['New jRC Repair/Replace ❑ Demolition
Describe Work: t1 O fl (01 rvAk, t 01
* * * * * * * * * * * * * * * * * * * * * * * * * * * *Fe * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ • b CCF $ ) .3 Q
Notary $ Training/Education Fee $ , rC 0 Technology Fee $
Scanning $ Radon $ Bond $ 3p a
Code Enforcement $
Structural Plan Review. $
Mechanical Roofing
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
/
Mortgage Lender's Name (if applicable) l�
Mortgage Lender's Address
City State Zip
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and AIR CONDITIONERS, ETC
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.
"WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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."
Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection will not ,be approved and a rei lion fee will be charged.
Signature
Owrf or Age
The foregoing instrument was acknowledged before me this `LI4
day of (9 , 200.)i by C_ I
who is personally known to me or who has produced a t •
Chc 10/14/03
NOTARY PUBLIC:
Sign:
Print:
As identification and who did take an oath.
S, !i1a1. ,`r
�� EXPIRES: September 16, 2007
18043- NOTARY FL Notary Discount Assoc. Co.
-e
My Commission Expires:
*** ******************** * * ** * *lk****ft** **ikiklkikik***** ** ik****** ik******* *l kf k************** ** *ik7kikitikiklk7k*** **** *R***
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * ** ** ** ************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED
Signature
NOTARY PUBLIC:
Sign:
Print:
My Commission
Contractor
The foregoing instrument was acknowledged before me this 7 3
day of FC h , 200 4; by CO Yu) , u■ j ayQ
who is personally known to me or who has produced D n
as identification and who did take an oath.
e . t � r Plans Examiner
Engineer
Zoning
:ONSTRUCTION
[0] New Sys
[ X] Repair
N
K
F
I
APPROVED BY:
STATE OF FLORIDA 1 1j
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION. PERMIT
PERMIT FOR:
t am [P Existing System
[ W] Abandonment
C . 1 1 -6 P 1 e
APPLICANT:
PROPERTY ADDRESS: - q 1 c 41.4,..A.A; 1.(
C: ( - 7
LOT: •---> ia BLOCK: ; - SUBDIVISION:
PROPERTY ID : Zn
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SAFTISFACTORY
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. ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T <7 0 ] GALLONS / GPD. SEPTIC .TAI■TIVA.EROBIC UNIT CAPACITY MULTI-CHAMBERED/IN I ]
A
[ __.,.. ] GALLONS / .GPD CAPACITY --" • MULTI-CHAMBERED/IN-SERIES [ ]
[ --- : ] GALLONS GREASE INTERCEPTOR CAPACITY (MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
[ .--- ] GALLONS DOSING TANK : CAPACITY • • 1 - ] GALLONS R L ] DOSES PER 24 HRS # PUMPS [ ]
• . , . , . .
D [ '& 0 0] SQUA PRIMA t D4AINFIELp : SYSTEM
R [ --- ] SQUARE FEE T ..' . . SYSTEM
A TYPE SYSTEM C : ('1 STANARD I. J./FILLED ' [ ] MOUND I ] _
I CONFIGURATION: : ,[1. TRENCH I -I BED E '
r. .." t \
LOCATION OF BENCHMARK: • I Z C.;- 0 AJ t1 4 '
ELEVATION OF PROPOSED SYSTEM SITE I 2 04 ] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE p0INT
BOTTOM OF DAAINFIELD BE [504 ] [INCHES/7T] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
, r 2 ,i.. ]
D FILL REQUIRED:. [ INCHES EXCAVATION REQUIRED: [
0
T
H ,.. .:-r.nr. , .: . :::::‘ , 1..• ,■••,,, :;:, -, ....4 - 1.c ,-. -.,•.t . •-■ .- -.• • ..• -.
E . pi , 'I
R ": ! .1 4 . ..:c 6 •, - 1. c., /.-- I.- (..,
• • ,, • . _ - •• . .
• - . .;•*--:' .,' - ';' - i• - v.-7 r '7? ' '' ' .... ri -..-- t ' • ': '• '. .---.'` f " -
SPECIFICATIOZCS BY 7 --; I" r:O..C c a t4..•
1 ( 1 \ . 1
_:z. 2,TIT . )..,1 . -77..,; ( 1, - 1:, --- 1*ki s ■r l A,r12tr i s . ' - i, .17:
1 1: - ....'.,,)..:;. , '„.i.. , .--,.':: .c': 7.1-: r=- -., ? I-4,- ,- r' - - • •. L.,
' V ( i 0 r'' .; ;..,....- -.-. - ..---, 7 - - - .- - . .- '. , . ,
• 1 - : i •.:,...A. _., „,.., am
TITLE: 1.,:l. - ° -
DATE ISSUED:
[ J ]
DH 4016, 12/9.9 (Page 1) (Previous Editions May Be Used)
. pt. 1: Health Department
pt. 2: Applicant
pt. 3: Installer/Contractor
pt. 4: Building Department
Holding Tank [ 0 ] Innovative
Temporary [ ]
pi I
PERMIT NO. aq - tu
DATE PAID: 2 V - Z 3 - 0 q
FEE PAID: 7 2V 4
RECEIPT #: d ??3.�
- - -; - 7 J
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX .ID NUMBER]
•
INCHES
EXPIRATION DATE: --
Page 1 of 3
'PLICANT:
)T: 5,6
ROPERTY ID #:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
Clinta& Staples AGENT: A American Septitt & Plumbing
BLOCK: 75
11- 3206 - 014 -2900
ROPERTY SIZE CONFORMS TO SITE PLAN: [Xa
OTAL ESTIMATED SEWAGE FLOW: 300
UTHORIZED SEWAGE FLOW: 1040
NOBSTRUCTED AREA AVAILABLE: 300
LEVATION OF PROPOSED SYSTEM SITE IS
;ITE SUBJECT TO FREQUENT FLOODING: [ ] YES
l0 YEAR FLOOD ELEVATION FOR SITE:
wbt, 3
;OIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture
l0yr 5V1 gc y cnnr11
liter 6i1 gr. y C:snr(
OBSERVED WATER: TABLE: n r INCHES [gyp. /
ESTIMATED WET SEASON WATER TABLE ELEVATION:
HIGH WATER TABLE VEGETATION: [ ] YES [K J NO
SITE EVALUATE)) BY:
74 r°
USDA SOIL SERIES: urban land.
OH 4015, 10196 (Replaces HRS -H Form 4015 [Page 3) which may be used)
(Stock Number: 5744- 003- 4015 -1)
SUBDIVISION: Miami Shores Sec 3
) BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
ROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTj )I{F Wx2]
GALLONS PER DAY [I5 OXWW1 CBE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: 600 SQFT
ENCHMARK /REFER:ENCE POINT LOCATION: ffe: 12.3 ngvd
1 „ 7 [ IRWIN/FT] (AAQVBELOW) BgR{ MK /REFERENCE POINT
HE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
IURFACE WATER: na FT DITCHES /SWALES: na FT NORMALLY WET? [ ] YES [XJ NO
(ELLS: PUBLIC: na . FT LIMITED USE: na FT PRIVATE:na FT NON- POTABLE: pf,0 FT
IUILDING FOUNDATIONS: 7 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 23 FT
Depth
to 74
to
to
to
to
to
to
to
to
72°
PERMIT �� ` U U 5 6
[Section /Township /Range /Parcel No. or Tax ID Number]
[X] NO 10 YEAR FLOODING? [ ] YES [X] NO
FT MSL /NGVD SITE ELEVATION: 10.6 FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell //Color Texture
1 (l y r Cf 1 `j r y s3'1r`
1 0 Ell ;ray
J
2'
Depth
tom
to 7 - °9
to
to
to
to
to
to
to
USDA SOIL SERIES: urban land
BELOW) EXISTING GRADE. TYPE: [PERCHED / APPARENT]
85,2 INCHES [ ABO / BELOW ) EXISTING GRADE.
MOTTLING: [ ] YES (K] NO DEPTH: II & INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: Bab table [ OTHER OF 30
DRAINFIELD CONFIGURATION: [ X] TRENCH [ ]
REMARKS /ADDITIONAL CRITER
DATE: /18104
INCHES
Page 3 of
;cale: Each block represents 10 feet and 1 inch = 4U feet.
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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT -
I 1. 4
Permit Application Number i t --d (f' n .O
PART II - SITEPLAN
Notes:
; t T1 ¢ ' -.. R 1 9 e r 41 s t - 3113P
exiS cing uraint,.ele overt1oWing- repiace drain±i.eid only
Iz
Site Plan submitted by: ,� ./
Plan Approved NI
` / Not Approved
By ' , /
•ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744- 002 - 4015 -6)
A
�� ✓7 T �f �L // Y
�.A
Date .. -
1 e County Health Department
Page 2 of 4
APPLICATION FOR:
[ ] New System
[ x] Repair
APPLICANT: Clinton Staples
AGENT:
PROPERY SIZE:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
SIGNATURE:
sfr
[ ]
[ ]
•
STATE OF/FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Existing System
Abandonment
A American Septic & Plumbing
[ x] RESIDENTIAL
3 2539
DH 4015, 10/97 - Page 1 (Previous editions may be used)
Stock Nurnber: 5744 - 001 - 4015 -1
MAILING ADDRESS: 17027 N Dixie ! wsgyMiami 23160
.42 ACRES WATER SUPPLY: [ ] PRIVATE
ne 96 st west to address
IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y / J
PROPERTY ADDRESS: 842 NE 96 st, miami shores 33138
• Other (Specify)
<7illiam Valnnriar*a
[ ] COMMERCIAL
C
PERMIT NO.
DATE PAID :C" - c. _ j
FEE PAID: / 4- ° tr O
RECEIPT i: U. 11 ,7! J
V — (' C � � 6
] Holding Tank [ ] Innovative
] Temporary ► ]
195 to nw 103. st east to biscavne blvd mouth to
DATE: 2/19/04
TELEPHONE: 3058065600
- -_ =�—
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
------ -- =___ _ = = = = ==--- "=== == = = == sa-- =__==== = == = ====== — = == =x==- --
PROPERTY INFORMATION
LOT: 5 BLOCK: 75 SUBDIVISION: Miami Shores Sec 3 PLATTED:1938
PROPERTY ID #: 1 1 - 3 2 0 6 4 - 2 9 0 0 ZONING: I/M OR EQUIVALENT: [ Y / N ]
[X]<= 2000GPD [ ] >2000GPD
DISTANCE TO SEWER: na FT
No. of Building Commercial /Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E -6, FAC
page 1 of 3
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204 Permit Number: PL2004 -68
Printed: 2/27/2004
Applicant: CLINTON
Owner: STAPLES
JOB ADDRESS: 842 NE 96
Contractor
Local Phone: (305) 866 -5600
Parcel # 1132060142900
Signed: (INSPECTOR)
Plumbing Permit
STAPLES
CLINTON
ST
A AMERICAN SEPTIC & PLUMBING INC Contractor's Address: 17027 W. DIXIE HWY
Legal Description: MIAMI SHORES SEC 3 PB 10 -37 LOTS 5 & 6 BLK 75 LOT SIZE SITE VALUE
Fees: Description Amount
FEE2004 -1893 Building Fee $175.00
FEE2004 -1894 CCF $1.80
FEE2004 -1895 Training and Education Fee $0.60
FEE2004 -1896 Technology Fee $4.37
FEE2004 -1897 Builders Bond $300.00
Total Fees: $481.77
Total Fees: $481.77
Total Receipts: $481.77
Permit Status: APPROVED Permit Expiration: 8/22/2004 Construction Value: $2,400.00
Work: INSTALL DRAINFIELD
Page 1 of 1
In consideration of the issuance to me of this permit, I 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) BY: