DRAINFIELD=.1
Plan Approved
,
_
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permit Application Number
I I ,
rIRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
'Stock NLmber. 5744-002-4015-6)
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PART II SITE PLAN
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Site Plan Submitted by
SIGNATURE
Not Approved
By,
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
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TITLE
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Date '
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County Public Unit
Page 2 of 3
LOT:
APPLICANT:
BLOCK:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
PROPERTY SIZE CONFORMS TO SITE PLAN:
TOTAL ESTIMATED SEWAGE FLOW: ,9(7Q
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE: �)
SUBDIVISION:
AGENT:
PERMIT #
PROPERTY ID #: /7 9y f �t [Section /Township /Range /Parcel No. or Tax ID Number]
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.
[ ] 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: Oce, SQFT
,('
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES /SW ES: �ft FT NORMALLY WET? [ ] YES [1\ NO
WELLS: PUBLIC: , �� FT LIMITED USE: /7J FT PRIVATE: AV //f FT NON — POTABLE: �/1 FT
BUILDING FOUNDATIONS: /O-/ FT PROPERTY LINES: /t) - }- FT POTABLE WATER LINES: ACJi- FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES pi NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture Depth
to
C.) to 1 1 r /
I 4 tom'
to
to
to
to
to
USDA SOIL SERIES:
10 YEAR FLOODING? [ ] YES [4 NO
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
to
to
T--. to
to
to
to
to
to
to
USDA SOIL SERIES:
OBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES (ENO MOTTLING: [ ] YES ( N0 DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [(] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
•7�
SITE EVALUATED BY: /��,�
ii
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which
(Stock Number: 5744 - 003 - 4015 -1)
not be used)
DATE:
Page 3 of 3
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c prC7!'_2:,:. .S.;i.:. > >. ;.'.. \YC ..f.. /t �..N" I ; F7V ,
APPLICATION FOR:
[pc] New System [ho] Existing System [no] Holding Tank [rip] Temporary /Experimental
[ Repair [ /?d] Abandonment [NJ Other(Specify)
APPLICANT: TELEPHONE:
e �^
r ti Grp l �, r - j L /y r3
AGENT:
MAILING ADDRESS:
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 1OD -6, FLORIDA ADMINISTRATIVE CODE.
PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
z
LOT: BLOCK: {t�SU$ftNIS3
/ 7
PROPERTY ID #:
PROPERTY SIZE:
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of
No Establishment
1
2
3
4
F / r
(1 Garbage Grind
[ Ultra - low Vd
APPLICANT'S SIGNATURE:
STATE OF FLORIDA
DEPARTMENT I v, HEALTf. ABILITATIVE SERVICES
ONSITE SEWAdWIASA
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381,'FS & Chapter 10D -6, FAO
ACRES [Sgft /143560]
[ A RESIDENTIAL
No. of
Bedrooms
4'
Building
Area Sgft
/Disposals [Api] Spas /Hot Tubs
Flush Toilets !jr
HRS -H Form 4015, Mar 92 (Obsoletes previous editions which may no,
(Stock Number: 5744- 001- 4015 -1)
(
[4 (Specify )
Cfrg
] COMMERCIAL
# Persons
Served
PERMIT #
DATE PAID
FEE PAID
RECEIPT #
/ -/a `✓ /h
$ �:J
. ci
/ 7-5=2-9
DATE: / - ;..1 �i / ‘
DATE OF _
SUBDIVISION. /'
[Section /Township /Range /Parcel No.] ZONING:
PROPERTY WATER SUPPLY: [ ] PRIVATE [ pa PUBLIC
Business Activity
For Commercial Only
[0d] Floor /Equipment Dra£ns
Page 1 of 3
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CONSTRUCTION PERMIT F9R:
[%l New System [Y1 (Existing System [P'] olding Tank [ Temporary /Experimental
[ ] Repair [Al Abandonment [Other(Specify)
APPLICANT: —/ - ,v AGENT:
PROPERTY STREET ADDRESS: // C f �� ✓e -�
LOT:
PROPERTY ID #:
D [2
R [ ] SQ
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: 2.
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
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.
SYSTEM DESIGN AND SPE IFICATIONS
T [ ]ts/ GP SEPTIC TA AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
SQUARE FEET
IMARY DRAINFIELD SYSTEM
SYSTEM
[ ] FILLED
[ ] TRENCH [ 404ED
[ ] STANDARD
I ELEVATION OF PROPOSED SYSTEM SITE [-
E BOTTOM OF DRAINFIELD TO BE [
L
D FILL REQUI :P4'. 112" OrfeittaMY COAYOASTAtitON REQUIRED: [
UNDER BOTTOM OF D
O D 1 ?^ ^JC alMli.sS 7� R TN P9'','
z4 Rr tl �t'x` .P,S.;'.rGl /2;nION
4
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
) [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
] [INCHES /FT] [ABOVE /BELOW] BENCHMARK /REFERENCE POINT
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744 - 001 - 4016 - 0)
APPLICANT
PERMIT #
DATE PAID
FEE PAID
RECEIPT #
[ ] MOUND [ ]
[ ]
] INCHES
EXPIRATION DATE:
CPHU
Gu Jo (`?7r �i
ym� iL� Us[ >I ®t u � C tlL yJ l C 2
:.i Page 1 of 2
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1?:;:nniZz.:ne:inc aurrtber y
!III:70 3f Fle:rr.iit, if ''C''llea° f;:20e,fy
owner's full 6U:11n.
nurn'Jc:•;:or cypiionni ccen1.
CV/::3 legary nutko:eti
¶07 ef,ert1.
Hinura :ci fierf.ionS !rem
spc.einen:icos from Che.pte:
u. sue': P.S 0i11I zequirementl;, '1W-vciurre.
•••::\IF: of individual orovidio! tiOfliEneci, by :1 eRsircs..• a....:31ecl.
?ublic HecIth 'Unit (C.."•?Z.11) crr eviewirg one approvinle ?emit.
2 : ). 2"c pe•ini: is issued by
• • yea clete isyu..fd if the ilrs no: been fo: byracni oeouirs become vu 90 ⁢
Legal Description
Owner's Address
Square Ft. A d 6 V
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date , H 14 job Address 6/pi qg Sr Tax Folio
I 70 e c ttt S-r-
Owner/Lessee / Tenant l- i S t vi H?cc v1
NE—
Contracting Co. 44 u VY-"1
Signature/ f - " erid/or Condo President Date
Notary as to Owner and/or President
My Commission Expires:
\‘ 11/ / '.TAMMY J SACHS
Public ` State of Florida E
My Comm. Exp: O5/07/99.<
�, `‘ Comml: CC480555
Date
1 - A 1 1 - '6
FEES: PERMIT 9Q, RADON C.C.F.
APPROVED:
Zoning Building
Mechanical Plumbing
Historically Designated: Yes No
Master Permit # 1(o O ( 0)
3 y
Phone S Sr H /
Address
SS# - / Phone e- 7 /e-I iZ
Qualifier Tr,14 ray
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 / gQ4
Estimated Cost (value) * 1 f 0
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 cons cti• and zoning. Furthermore, I authorize the above -named contractor to do the work stated.
S
Notary as to Contracto
My Commission E
for or Owner- Builder
er- Builder
`1111, 1 � x..tg ; rtv
Notary _° "ACHS
= �rida
Public
� ►� c . 05/07/99i
7: 2 „ / „ ! 4 a Coma. » ,.,.;460
NOTARY TOTAL DUE
Electrical
Date
Date
Engineering