40 NE 98 St (3)Date 4
Legal Description 4-(7 / + F 8// 7 Historically Designated: Yes No
/ Tenant (� / l 2-/9'00)1 (,/1/7t/5, Master Permit #
. Owner's Address / / / Phone
il k Contracting Co. Zk-S ,C / r --- ,1)/2 -R"i/t Address / O a'O PC /30 5 / t
Qualifier 6 hiZ PA /14 SS# J J O J O /Y
State # S / - 9 t' Municipal # G Al F7 /t Competency # / I )) Ins. Co.
Square Ft.
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
00 Job Address 1 / 0 41 C ( S , Tax Folio 1/ 330-66 013 093°
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL (PLUMBING CHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION
c 9- (-XS i ! Estimated Cost (value) /6 CS
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
con . ction and zoning. F ermore, I authorize the above -named contractor to d . _ . or . ted.
L /..:!� of Milli/./.._ G-(9-66 / /
"". t ur er and/ `Z t �� Date • er -Boil'
��ff 7� fs
No : as to Owner ifl4d'
y Commission Expire,: C;LADYSI V1LLAR
NOTARY I'URIJC STATE OF FLORIDA
COMMISSION NO. CC/14103
MY COMMISSION EXP. MAR 1
FEES: PERMIT
RADON
APPROVED:
Zoning Building
Mechanical Plumbing
a 7)gn
� 0
C.C.F.
of ontracto
Fl ar 5
GLADYS VILIAR
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO. CC7L4103
MY COMMISSION EXP. MAR.1
•
Signa
Notery as to Contractor or Owner- Builder
My Commiss
Date
NOTARY BOND
3
TOTAL DUE 5v Z
6 - /f -o0
Date
Electrical
Structural Engineer
CONSTRUCTION PERMIT F R: i / ►
WI New System [ Existing System [1' Holding Tank [ tv e' ]
4 [] Repair [I ] Abandonment [j Other(Specify)
t
APPLICANT:
PROPERTY STREET ADDRESS: 4
LOT: 4.
PROPERTY
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
8 "
ID #: 1
.E [
? t r : 1'-i L E ,
LOCATION OF BENCHMARK:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, F
BLOCK: ;[f1 SUBDIVISION:
ELEVATION OF PROPOSED
BOTTOM OF DRAINFIELD
++ 1� ]
FILL REQUIRED: [�.1 16) INCHES
!,i43 a [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
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. DEPARTMENT OF HEALTH 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.
•
/ y
SkST . SId AID pPECIICATIONS
T [1St)] S1)] [GALLONS / GPD]
A [ ] [GALLONS / GPD] CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK: •R
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE ATE [ ] PER 24 HRS NO.
DH 4016, 10/96 (Replaces HRS -H Form 4016 (page 1] which', may be u;dF
(Stock Number: 5744 - 001 - 4016 -0) r .
SEPTIC TANK /AEROBIC UNIT CAPACITY
`)] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ ) SQUARE FEET
TYPE SYSTEM:
CONFIGURATION:
SYSTEM
[ . I STANDARD [ dk.P FILLED [4 MOUND
?,,, J TRENCH [1/4 BED [A.
SYSTEM SITE [1''7 ] [I ,'.ES/ [ABOVE /B BENCHMARK /REFERENCE POINT
TO BE [ 4 / j ] [ S /FT] [ABOVE/ BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [c,t. INCHES
INSTALL F LOAMY COARSE SAND
UNDER BOTTOM OF DRAINFIELD
\I v n
Ilium tLEvATION-5 o
BOTTOM OF CAAitsEOM ELBIATIXI f I
PERIMETER CC EXCtVITION MCA SHALL CZ
AT LEAST 2.0 FEET WIDER AND to :IR.31 MAN TIDE
PROPOSED ABSORPTION BED OR DRAIN TRFI:01
TITLE:
tA
- 1 N •
•
. , , ter
APPJ .
, FAC
AGENT: i
PERMIT # °%k, ` 0 - f
DATE PAID . it ? ,. J 3
FEE PAID $ 7, .)
RECEIPT #'+.,F,41( ! 3 >
Temporary /Experimental
girMA
eN
MULTI- CHAMBERED /IN SERIES:[ )
MULTI- CHAMBERED /IN SERIES:( )
1250 GALLONS)
OF PUMPS: [ )
[ /'1
/4 tM.0
EXPIRATION DATE
•
a L L
•
Page 1 of 2
CHD
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 IOD -6, FAC.
DRAINFIELD: Minimum specifications from Chapter 1OD -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 10 feet and 1 inch = 40 feet.
4' .-
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT 2
Permit Application Number - - o �! ,✓� �
By
Site Plan submitt by:
Plan Approved
/9. 0
l
sac.) l p/c,
. Date _1
County Health
ALL CHANGE MUST BIE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Not
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744 -002 - 4015 -6)
PART II - SITEPLAN
r• e
Page 2 of 4
VISSNIBMI
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- Scale: Each block represents 10 feet and 1 inch = 40 feet.
4' .-
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT 2
Permit Application Number - - o �! ,✓� �
By
Site Plan submitt by:
Plan Approved
/9. 0
l
sac.) l p/c,
. Date _1
County Health
ALL CHANGE MUST BIE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Not
DH 4015, 10/96 (Replaces HRS -H Form 4015 which may be used)
(Stock Number: 5744 -002 - 4015 -6)
PART II - SITEPLAN
r• e
Page 2 of 4
APPLICANT:
LOT: Iffy BLOCK: 1 SUBDIVISION: t I(1 i S /ore -r PROPERTY ID # :l! - 32c‘ - 0 13 -6530
AGENT:
PROPERTY ADDRESS
=- -- •--- ••- sssa= aaxaasana
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE
TANK
[01]
[02]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[
[18]
[19]
[20]
[21]
CONSTRUCTI
FINAL SYS
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
� L i s 6' r t-1 iv1`
INSTALLATION � EXi 7 4# Il(v
TANK SIZE [ [
TANK MATERIAL C-O NGRC %! Cam'
OUTLET DEVICE 9 '�-
MULTI- CHAMBERED [ Y /
OUTLET FILTER N/4
LEGEND NI4
WATERTIGHT gi
LEVEL Qsk
DEPTH TO LID 'f of
DRAINFIELD INSTALLATION
AREA (11523 V- [2]
ISTRIBUT
NUMBER OF DRAINLINES 3
DRAINLINE SEPARATIONS .
DRAINLINE SLOPE " (19t to qt4e
DEPTH OF COVER
ELEVATION [ABOVE
SYSTEM LOCATION
DOSING PUMPS NIA
AGGREGATE SIZE-4:5
AGGREGATE EXCESSIVE FINES e1
AGGREGATE DEPTH17"
EXPLANATION OF VIOLATIONS / REMARKS:'.
DISAPPROVED] :X
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT O'
[23] FILL TEXTURE Oft
[24] EXCAVATION DEPTH Y 2' C
(251 . AREA REPLACED 1Y X ! J
[26] REPLACEMENT MATERIAL r [
DE 4016, 10/97 (Previous Editions May Be Used)
ISAPPROVED] : /411
Applicant
PERMIT 1T0. C 0 70
DATE PAID: • In l 9 -ow-
FEE .PAID: 7SGv
RECEIPT #:5 BOa6'l goo
OR RULE AND MUST BE CORRECTED.
SETBACKS
[27] SURFACE WATER 4- FT
[28] DITCHES 4/ FT
[29] PRIVATE WELLS /v . FT
(30] PUBLIC WELLS � FT
[31] IRRIGATION WELLS 14 FT
(32] POTABLE WATER LINES //O FT
[33] BUILDING FOUNDATION 4 FT
[34] PROPERTY LINES FT
[35] OTHER , FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40]
[
[
[43]
[44)
[45]
[46]
[
[48]
FINAL SITE
CONTRACTOR
OTHER
CND
• UNOBSTRUCTED AREA
STORMWATER RUNOFF
ALARMS
MAINTENANCE AG
BUILDING AREA 6 7
LOCATION CONFORMS WITH SITE
ABANDOIDIENT
[49) TANK PUMPED 66 /L11/ fld ».,
[50] TANK CRUSHED & FELLED _ / /
]
]
]
DATE: 6 d°-O
DATE: 6 �o
Page 2 of 3'