DRAINFIELDQualifier
Date Job Address 1/60 N C • 9 g1'T - Tax Folio
Legal Description Historically Designated: Yes No
Owner/Lessee / Tenant A�//t • l9� // P .4i i 3 8._\
Owner's Address //6o N•g • g/,- Phone 7_57- 3 90
Contracting Co. /t C .c /.6_ 5 0,,,,...3 Address l q9.3 z "1,0 • p' . liat,itAce
S7 a << /a
State # fi • Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
A ce,, c2z24 'e. /0( '
WORK DESCRIPTION
Square Ft. 30-0 Estimated Cost (value) , /000,
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 an zoning. Furthermore, I authorize the above -named contractor to do the work stated.
Notary as to Owner
My Commissiw
1 40F RA'
FEES: PERMIT 3S. e RADON
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
ondo President Date
BURDINE THOMPSON
My Commission CC409057
* Expires Sop. 22, 1998
Bonded by HAI
800 -422 -1565
or Condo President Date
APPROVED:
Zoning Building
Mechanical Plumbing
SS# - Phone s ' 7R57
Signature o ntractor or Owner- Builder Date
N. ary as to
y Commissio
C.C.F. • NOTARY
Master Permit #
ontrasy or
*
Electrical
er- Builder
BURDINE THOMPSON
My Commission CC409057
Expires Sop. 22, 1998
Bonded by HAI
800- 422 -1555
TOTAL DUE
Engineering
,3-1f
,a - /3 • 7-e
Date
CO STRUCTION PERMIT FOR: -4' -
,[V] New System Existing System [ ;', Holding Tank ( ]Temporary /Experimental
0 ] Repair ( ] Abandonment [`�] Other(Specify)
x
APPLICANT: A A
PROPERTY STREET ADDRESS://4
LOT:
PROPERTY ID #: P/'
SYSTEM DESIGN AND S ECIFICATIONS
T
A
N
K [
D
R [
A
I
N
F
I
E
L
D
0
T
H.
E
R
]
]
TYPE SYSTEM:
CONFIGURATION:
LOCATION OF BENCHMARK: ®'��°✓"
ELEVATION OF PROPOSED SYSTEM SITE [
BOTTOM OF DRAINFIELD TO BE [
APPROVED BY:
DATE ISSUED : 2 v
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
e`-et, r '' � J
[
[
BLOCK: SUBDIVISION:
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.
]CQlLLBNS / GPD SEPTIC �TTJ.LK1 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: [ ]
SQUARE FEET PRIMARY DRAINFIELD SYSTEM
SQUARE FEET SYSTEM
] STANDARD [ ], FILLED
TRENCH [] BED
FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [
_N3TAL °.r' t,1 LOAMY C3fRS2 ';;; ;11))
4.)1 LT5L 1,0 a ";' 0 14 h DRh,:;I
J..3 �.., q �j wu �r �.FF �
lyfir.A .5.4'i1�d.aa. .�`..C'�. ,�v'•A`� �
SPECIFICATIONS BY:
)
)
APPLICANT
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
[INCHES /FT]
[INCHES /FT]
'1\
AGENT:
r
C.12
TITLE:
[ ] MOUND
[ABOVE /BELOW]
[ABOVE /BELOW]
PERMIT #
DATE PAID
FEE PAID
RECEIPT #
[ ]
] INCHES
ASTALLEii OM TUE OUTLET T
HRS-H Form 4016, Mar 92 (Obsoletes previous editions wh c "may'not be used)
(Stock Number: 5744 - 001- 4016 -0)
S
[
BENCHMARK /REFERENCE POINT
BENCHMARK /REFERENCE POINT
TITLE: CPHU
EXPIRATION DATE:
f'
Page 1 of 2
APPLICANT: i f i r t J , m , - e,
LOT:
PROPERTY ID #:
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: 400
AUTHORIZED SEWAGE FLOW: 4 7 . S . O
UNOBSTRUCTED AREA AVAILABLE: 400
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE :
SURFACE WATER: /GAO FT DITCHES /SWALES: /0,6 FT NORMALLY WET? [ ] YES [ NO
WELLS: PUBLIC: ('' FT LIMITED USE: A/ /4 FT PRIVATE: /464 FT NON- POTABLE: ^//2L. FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: ® FT /(00'1'ALE WATER LINES: Sb FT
SITE SUBJECT TO FREQUENT FLOODING:
10 YEAR FLOOD ELEVATION FOR SITE:
SOIL PROFILE INFORMATION SITE 1
Mun
11 Color Texture
USDA SOIL SERIES:
Depth
/tom
/2 to Z
2.y to
to
to
to
to
to
to
OBSERVED WATER TABLE: 40 4 [ABOVE /
ESTIMATED WET SEASON WATER TABLE ELEVATIO :
HIGH WATER TABLE VEGETATION: [ ] YES [ NO
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING•
DRAINFIELD CONFIGURATION: TRENCH [ ]
[ ] BED [
REMARKS /ADDITION1I CRITERIA:
SITE EVALUATED BY:
STATE OF FLORIDA PERMIT # 4176'&
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
BLOCK: SUBDIVISION:
[ ] YES
NRS -H Form 4015, Mar 92 (Obsoletes previous editions
(Stock Number: 5744- 003 - 4015 -1)
[Section /Township /Range /Parcel No. or Tax ID Number]
YES [ ] NO NET USABLE AREA AVAILABLE: ACRES
GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: �®® SQFT
[INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
[./NO 10 YEAR FLOODING? [ ] YES [ N0
FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
d C / � .
� sedi ' �
•
SOIL PROFILE INFORMATION SITE 2
Muns =11 Color Texture Depth
_s --1.--
c cif AD /z to/
E
USDA SOIL SERIES:
to
to
to
to
to
to
EXISTING GRADE. TYPE: [PERCHED / APPARENT]
INCHES [ ABOVE BELOW ] EXISTING GRADE.
MOTTLING: [ ] YES [VI NO DEPTH: INCHES
DEPTH OF EXCAVATION:
] OTHER (SPECIFY)
INCHES
P.;
DATE: !o /3 g
Page 3 of 3
I
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
APPLICATION FOR:
[ A l New System. [ ] Existing System [ ] Holding Tank [ ] Temporary /Experimental
[WI Repair [ ] Abandonment [ ] Other(Specify)
APPLICANT: e/ #-, t ;o f , 1 E'.
LOT: BLOCK: SUBDIVISION:
PROPERTY ID #:
PROPERTY SIZE:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
lad4404
[ ] Garbage Grinders /Disposals
[ ] Ultra -low Volume Flush Toilets
APPLICANT'S SIGNATURE:
NRS -N Form 4015, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001- 4015 -1)
PERMIT #
DATE PAID �r //''&•
FEE PAID $ 4
RECEIPT #
TELEPHONE: 175/_:31
AGENT: �S /_ ;
c
MAILING ADDRESS: 4:
��5r� ( P � 2
C� . 0 v4 73 • •
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, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
DATE OF
SUBDIVISION: G
[Section /Township /Range /Parcel No.] ZONING:
(pi] RESIDENTIAL [ ] COMMERCIAL
No. of Building # Persons
Bedrooms Area Saft Served
boo
[ 1 Spas /Hot Tubs •
DATE:
ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE ($4 PUBLIC
PROPERTY STREET ADDRESS: //( 4! , � 98AQd• A49e77I p
s7 BAG
Business Activity
For Commercial Only
[ ] Floor /Equipment Drains
[ ] Other (Specify)
Page 1 of 3
• v(:
•
,E •
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n
.. .i - C'.' �..
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONS PERMIT
Permit Application Number
' X 76 6.
• Each block represents 5 feet and 1 inch = 50 feet /VC d 6 -t
Notes C Ta i4 0 , o'
14_ ( I i oft (.) t'e> i
Plan Approved
By
PART II - SITE PLAN
2 s 10,4,,69(pt 4,0,6,-) 3
_ V
Not Approved
j
TITLE 6
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015 -6)
--�' County Public Unit
Page 2 of 3
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STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONS PERMIT
Permit Application Number
' X 76 6.
• Each block represents 5 feet and 1 inch = 50 feet /VC d 6 -t
Notes C Ta i4 0 , o'
14_ ( I i oft (.) t'e> i
Plan Approved
By
PART II - SITE PLAN
2 s 10,4,,69(pt 4,0,6,-) 3
_ V
Not Approved
j
TITLE 6
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS -H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744 - 002 - 4015 -6)
--�' County Public Unit
Page 2 of 3
Permit No.
Amount of Permit $
Application is hereby made f r 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 herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address
Registered Arcbitect and /or Engineer_
Employing Plumber's Name 2240— . i —G 411ALENCE--- ___ -_._ No..
Location and Legal Description Lot_ Block.
Street and Number where work is to be performed —No Street
State work to be performed and purpose of building (By Floors)_. ..__ 1 /4.. 1
New Building Remodeling------ _.- .------- _--- - -__ -- Addition
MIAMI SHORES VIL yAGZ
PLUMBING INSPECTION DEPARTMEM'
APPLICATION FOR PLUMBING 7: ;b4AIT
No.___
(Signed) —_
(Signed
Date
Street-__
My Commission Expires Notary Public, State of Florida
gr-
Subdivision
Repairs No. of Stories . . ......... . ..
Size Septic Tank — Type of Tank
Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City — Well._______ — _ __._Size of Soakage Pit
Capacity Gals
Master Plumber.
Plum . frig Ins . tor.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his , �Pations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5968, Compiled General Laws of Florida Pe • • nent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractor 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 performe• - nder this permit, as are
licensed by Miami Shores Village.
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.
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
TUBE
SHOWERS
LAVA-
TORIES
INK
SINKS
SLOP
SINKS
LAUNDRY
TUBS
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
5402-1
- - --
Permit No.
Amount of Permit $
Application is hereby made f r 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 herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address
Registered Arcbitect and /or Engineer_
Employing Plumber's Name 2240— . i —G 411ALENCE--- ___ -_._ No..
Location and Legal Description Lot_ Block.
Street and Number where work is to be performed —No Street
State work to be performed and purpose of building (By Floors)_. ..__ 1 /4.. 1
New Building Remodeling------ _.- .------- _--- - -__ -- Addition
MIAMI SHORES VIL yAGZ
PLUMBING INSPECTION DEPARTMEM'
APPLICATION FOR PLUMBING 7: ;b4AIT
No.___
(Signed) —_
(Signed
Date
Street-__
My Commission Expires Notary Public, State of Florida
gr-
Subdivision
Repairs No. of Stories . . ......... . ..
Size Septic Tank — Type of Tank
Feet of Drain Tile Dist. Feet of Tank or Drain Field from Well
Nature of Water Supply: City — Well._______ — _ __._Size of Soakage Pit
Capacity Gals
Master Plumber.
Plum . frig Ins . tor.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his , �Pations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5968, Compiled General Laws of Florida Pe • • nent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractor 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 performe• - nder this permit, as are
licensed by Miami Shores Village.
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.
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.