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Date $ - a 6 - o o. Job Address // 9 o iv . F'. 9 Tax Folio //- 301 O 3 - 01 8 - 0.3 g` O.
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant ( 3 e r Apo
C o n t r a c t i n g Co. /),.-A i s Ai ePd N $T r J
WORK DESCRIPTION
Square Ft.
FEES: PERMIT
APPROVED:
Zoning
Mechanical
o
/ _. %Ai1
,nature •••
wner and/or Condo
Notary as to Owner and/or Condo President
My Commission Expires:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
O RADON
Set e T 4 QrAJ f,..Pd
resident Date
ANNA QUINONES
MY COMMISSION # CC 883662
EXPIRES: Oct 28, 2003
1 4003- NOTARY rle: Nm ty IAMVIAR A Minding O0,
Building
Plumbing
L- - oo-
Date
Estimated Cost (value) 1. .
C.C.F. / ' V NOTARY
Master Permit # R, S . d aP- / 8s
Owner's Address //1" O A)._ /' 9 , Phone 3 o S
10-r Address /3bq w -4.- 7Y t-
Qualifier Mg..4 r u SS# Phone 3 O$ - 9 Y o- a it .
State # 00 S S 6 , Municipal # Sao OO O SsoC , Competency # S, oo v ss r . Ins. Co. U N; Ted AM-TI ous0
Architect/Engineer A . Address
Bonding Company 144 Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBIN MECHANICAL ROOFING PAVING FENCE SIGN
WARNING TO OWNER: YOU MUST RECORD A NOTICE OF COMMENCEMENT AND YOUR FAtILU TO DO SO MAY
RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY (IF YOU INTEND T O TAIN FINANCING,
CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF CO NCEMENT,)
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 re ating construction and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Sign of Contract g r Owner - Builder Date
1-
Notary as to Contractor or Owner- Builder
My Commission Expires:
Electrical
1,. EtyES
6/
6 - s".
Date
TOTAL DUE,
Engineering
T
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STATE OF FLORIDA'
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter- 381, FS & Chapter 10D--
PAC
PERMIT
DATE PAID
FEE PAID $
RECEIPT >
CONSTRUCTION PERMIT FOR:
[ Ni New System [ N Existing System [ j] : Holding Ttnk
Repair Abandonment f Other S eci;f. �
. '+Temporary /Exper
APPLICANT: . F
(' a,(1 es Qr 4 a Ay AGENT: ` , �
PROPERTY STREET ADDRESS: s
Z 1 LOT: BLOCK: / d SUHDIVISION: Kr ao . d, s 5',r c
PROPERTY ID #: [SECTI.ON /'TOWNSHIP /RANGE / OEI, NUME5R
/1 -=, Z OS- U .�/1 Z,r R TAX ID NUNBERJ ,
SYSTEM MUST BE CONSTRUCTED .TN ACCORDANCE WITH SPECIFICATIONS . STANDARDS Q
FAC. REPAIR PERMITS AND HOLDING. TANK PERMITS EXPIRE'9O DAYS'FROM THE DATE OF i
PERMITS EXPIRE ONE YEAR FROM THE DATE OF ISSUE. DEPARTMENT OF HEALTH APPROV
NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC'PERIOD or TIME, ANY
FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF . TRIS PERM' '' U0p1,RE.THE APPLICANT. M
PERMIT APPLICATION. SUCH MODIFICATIONS' MA 1400
_ rn.
SYSTEM DESIGN AND SPECIFICATIONS
rc f�
[ g go e ' -
0 [ / / GPD) ROBIC UNIT CAPACITY M1x CHAMBERE
[ ] [GALLONS / GPD ] CAPACITY MULIT - ±CH BERED/I
( ) GALLONS GREASE', INTERCEPTbR CAPACITY rmAxI1 1 ' CAPACITY 'pr Otte
[ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE ;RATE [ ] PEI` 4 HRS 4 NO
[ 3 6 0 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ IJ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ 4 STANDARD [ ] FII„LED ..
CONFIGURATION: [ ] [ JeBED
LOCATION OF BENCHMARK: /'/d l -t cz. • ( t Rd yf •
ELEVATION OF PROPOSED SYSTEM SITE [ ,� ] FT[ :ABOVE/
BOTTOM OF DRAINFIELD TO BE [ ] FT) [ABOVE
sat go
FILL REQUIRED: [ p m ] INCHES EXCAVATION REQUIRED: [ 301 •INCITES
SPECIFICATIONS B
APPROVED BY:
DATE ISSUED:
DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1) which may be used)
(Stock Number: 5744- 001- 4016 -0)
Applicant
BENCHMARK/
BENCHMARK/
omm
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
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. (Health Department may require property appraiser ID# or
section /township /range /parcel number.)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK: Minimum specifications from Chapter 10D -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -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 Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
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.
Scale: Each block represents 5 feet and 1 inch = 50 feet.
coo -two
t '1 W o
f ef LA( �►1ev ' /D$ OtMJ
Notes:
Site Plan submitted by:
Plan Approved
By
11 .,
DH 4015. 10/96 (Replaces HRS.H Form 4015 which may be used)
(Stock Number: 5744 -002- 4015 -6)
Co 1 rd
Signature
Not Approved
�� 11
PART II - SITE PLAN
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PETollb ,� f
Permit Application Number U�
y
Ai 0j,
1 0 o lJ , r .
P r y
ALL OHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Titl
Date 6 ' ('-
i " /^,14a County Health Department
Page2of3
APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE‘EVALUATION. SYSTEM SPECIFICATIONS
`5a.
l - 2 I , Pr.vw
LOT: / BLOCK: �� u SUBDIVISION:
AGENT: , /1/,1,40'
PROPERTY ID f: //-30..1 0 3 o , [Section /Township /Range /Parcel
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ]
TOTAL ESTIMATED SEWAGE FLOW: 300
AUTHORIZED SEWAGE FLOW: 5/ 7
UNOBSTRUCTED AREA AVAILABLE:
G
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE
SURFACE WATER: 0)1 FT DITCHES /SWALES:
WELLS: PUBLIC: & ) )' . FT LIMITED USE: ),J 0 • FT
BUILDING FOUNDATIONS: SO, FT PROPERTY LINES:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD
S'f /a] y, o Al _ t ,
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture
)O y r y/ _4x44•
/ 'J)
USDA SOIL SERIES: Ur bw- LAkad I
Depth
to
to
to\ G 0
(� o•'to
to
to
to
to
to 7i'
SITE EVALUATED BY:-�� ,
n�
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Pape 3] which may be used)
(Stock Number: 5744 -003 - 4015 -1)
YES [1 O NET USABLE AREA AVAILABLE: 0. 1.06 • ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: G o 0. SQFT
-77J12 OF / p, r,
O. /FT) [ABOVE/B34 BENCHMARK /REFERENCE POINT
s =m
PROPOSED SYSTEM TO THE FOLLOWING FEA
d) j 4 . FT NORMALLY WET? [ ] YES "'l 1 NO
PRIVATE fP 'FT NON- POTABLE: so. FT
.5.17 FT POTABLE WATER LINES: /0. FT
10 YEAR FLOODING? [ ] YES [ ) NO
SITE ELEVATION: e• 7 , FT MSL /NGVD
K Per_
SOIL PROFILE INFORMATION SITE 2
ax,:.r.. rc "'ems• "+✓'i'>�wb�v -
PERMIT # we-as
No. or Tax ID Number]
Munsell # /Color Texture Depth
)fl C ,d. a to
to
to 6
Jo r d/ 3 L / r'l -e.,7 4 p'' to
r to
to
to
to
to j!
USDA SOIL SERIES: Li r b w L4.,/ .
1
/ OBSERVED WATER TABLE: / 4 INCHES [ABOVE / EL J1] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WA / ER TABLE ELEVATION: _5-GglILVEI ABOVE /) EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ) XES ( ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: 0 . 7 'D• DEPTH OF EXCAVATION: ;Lk INCHES
DRAINFIELD CONFIGURATION: L. ] TRENCH [ BED ] OTHER (SPECIFY)
,.,€
REMARKS /ADDITIONA ITERIA: l. -- - „ ---- j ! ' ; ` 1 ' n
/ f r ;.••
DATE: 6 - .1-00
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
UNOBSTRUCTED AREA:
MINIMUM SETBACKS:
Record the estimated sewage flow for the establishment from Table 1 (residence) or Table 2 (non - residential),
Chapter 10D-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter 1OD -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE 1 SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.1.
H.I. [ - ] SHOT [ - ] SHOT
[ - ]SHOT
BUILDING
ELECTRICAL
PLUMBING
•
s Owner of
4 u}lding
Architect
Contractor
or Builder
Legal
Description
Address of
Building
Lot
MIAMI SHORES VILLAGE, FLORIDA
DATE
PERMIT N° 5818
Work to be performed under this Permit
(R..," A / aod
11 B1.
This permit is granted to the contractor or builder named above to construct the building or to install the equipment or device described in the appli-
cation herefor in strict compliance with all ordinances pertaining thereto and w th the understanding that the work will be performed in compliance with any
plans, drawings, statements or specifications that may have been submitted to and approved by the proper municipal authorities. This Permit may be revoked
at any time if the work is not done in compliance with such ordinances or if the plans are changed without authorization. A further condition upon which this
permit is granted is the understanding that the contractor or builder named above ass n the res.onsibility for a thorough knowle tie ordin and
regulations pertaining to the work covered hereby whether shown on the plans ^ "ngs �� �.. ate _ eats or ecifications �lti m�spon-
sibility for work done by his agents, servants or employees.
In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all or . ,
c&s and r ' d 0
pertaining thereto and in s ict conformity with the plans, drawings, stateme is or spec ications submitted to the proper authorities MIgilarni Shores Village.
In accepting t `s permit I a.ume r-. -. ibility for all work done by e* a y self, my . •nt servant or emp
a. I
LA <. ,f...i "_.. #/
NTRAC oft OR BUIL
Subdi-
vision
s
Contractor's
License No
19
/39C (.4.11)
Value of Amt. of ilk
Project Permit A �►
alb
Signed ' By
SP C •It
AUTHORITY