600 NE 98 St (5)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date ) 3 J o b Addresso /U/ 1 t S f Tax Folio
Legal Description
Owner/Lessee / Tenant t i � a 4 m, dp4 Master Permit # 1. 1kei l i C 7
Owner's Address e"O 4 G _ 9 Phone ° S 6 o ( 7E355'
5'
Contracting Co.- M �. C s � p�p l j/; bY I "1C: Address
Qualifier C ' a I— k.fin SS # Phone >; - X51- 2 .1
State # Municipal # Ins. Co.
Architect/Engineer
Bonding Company
Mortgagor Address
Permit Type (circle one): BUILD /G.C�
�
G ELECTRICAL PLUMBING MECHANICAL ROOFING PAVING FENCE SIGN
7 a IGN
1 1 a I 0 4 1
1 `
WORK DESCRIPTION
Square Ft. —0 Estimated Cost (value) /) 6v
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.
OWNERS 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. Furthermore, I authorize the above -named contractor to do the work stated.
Signature of owner and/or Condo President
D
otary as to Own
My Commissi
FEES: PERMIT
APPROVED:
Zoning
Mechanical
‘i.?./ PQZ1i/ �c
d/or Condo President Date
`9
RY
P
OF P.
TARY SEAL
OFRCI N
c
� P
C� COMMISSION NUM
• •1
R
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Niy N EXPI
DEC. 17,2002
60.
RADON
0
S
Date
C.C.F.
Historically Designated: Yes No
Competency #
Address
Address
Signature of Contractor or Owner- Builder
co C / /f /aa53
Notary as to Contra or or Owner - Builder
My Co / s pgAROARIT r SEA p �
COMNASaON NUMBER
F � . d JY COM ON EXPIRES
a C C797277
�� OF F`O DEC. 17,2002
NOTARY , 5 BOND gre)
Electrical
•
Date
TOTAL DUE a 5 4
Structural Engineer
' APPLICANT:
LOT: / 12 , BLOCK: /0/
PROPERTY ID #: 3 A-4)6 - 0/7 _ r p 410 [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.
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ] YES [ ] NO NET USABLE AREA AVAILABLE: 041% ACRES
TOTAL ESTIMATED SEWAGE FLOW: 36D GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: sZ GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: 6 01) SQFT UNOBSTRUCTED AREA REQUIRED: 6016 SQFT
/1. /40 U f i
BENCHMARK /REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS /P LING S /FT] [ABOVE •. HMARK FE
THE MINIMUM SETBACK WHICH
SURFACE WATER: D O FT
WELLS: PUBLIC: (4 /& FT
BUILDING FOUNDATIONS:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE
DITCHES /SWALES: / FT NORMALLY WET? [ ] YES [ FEATURE,:
LIMITED USE: / FT PRIVATE: r FT NON - POTABLE: » FT
FT PROPERTY LINES: 2 FT POTABLE WATER LINES: 25 FT
7
OH 4015, 10196 (Replaces HRS -H Form 4015 (Page 31 which may be used)
(Stock Number: 5744 - 003 - 4015 -1)
SUBDIVISION:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [0 NO 10 YEAR FLOODING? [ ] YES [ y'
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: .5'•4 FT MSL /NGVD
SOIL PROFILE INFORMATION SITE 1 7'L PO SOIL PROFILE INFORMATION SITE 2
SITE , EVALURTE
AGENT: 4. e i
Muns211 #(Color Textu Depth
/9°J �./ .j to
to 17 4 v i D ✓' OI 0 4 to767
2 AM!! 1. , 1 , to 2
S' / to—J
3 / LI
PERMIT #
USDA SOIL SERIES: Gy
to
to
to
to
OBSERVED WATER TABLE: &L iiCH [ABOVE / BEL W�EXISTING GRipi TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: 67'2: INCHES [ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [Loi NO MOTTLING: [ ] YES [NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: /'D DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [ (/] BED [ ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE: //5/20:›0
Page 3 of 3
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STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 38
CONSTRUCTION PERMIT FOR:
A l Existing System
) Abandonment
0
T
E
R
New System
Repair
PROPERTY STREET � ADDRESS: G '�
f �C�s
LOT: BLOCK: SUBDIVISION:
(1 M D
PROPERTY #:
R [ ®-]
A TYPE SYSTEM:
I
N
of -
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
SYSTEM DESIGN AND SPECIFICATIONS
T [ [GALLO/ GPD]
A [ I "I [GALLONS / GPD)
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY
K [ ] GALLONS PER DOSE DOSING TANK CAPACITY
CONFIGURATION:
F LOCATION OF BENCHMARK: �; o
4 JINCHES I
E
D FILL REQUIRED: [ „
ELEVATION OF PROPOSED SYS 1
BOTTOM OF DRAINFIELD TO BE [ f
01 1 aai
DH 4016, 10/96 (Replaces HRS -H Form 4016 [page 1] which may
(Stock Number: 5744- 001 - 4016 -0)
SQUARE FEET PRIMARY DRAINFIELD SYSTEM
SQUARE FEET • SYSTEM
TIC TANK
( ] Holding Tank
[ ( j Other(Specify)
AGENT:
w( , / iii RCEL ��
[SECTION /T WNSHIP /RANG /'PA NUMBER)
D a^ �� 0 D A Q , 0 [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.PFRIOD 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.
AEROBIC UNIT CAPACITY
MULTI- CHAMBERED /IN SERIES:[ ]
CAPACITY MULTI- CHAMBERED /IN SERIES:[ )
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS) RATE ATE [ ] PER 24 HRS NO. OF PUMPS: [ ]
[ STANDARD [ ] FILLED [ J MOUND [ ]
[ e TRENCH [ ] BED [ ]
drh4r
S /FT]
EXCAVATION REQUIRED:
TITLE:
B
[ O emporary /Experimental
n
fi � VE /L1 IJLBENCHMARKAEF R CE ,HINT
[ABOVE /BELOW] BENCHMARK /REFERENCE POINT
c awav 6Q OE 00a
Vie IEEE GJ PATI GC7 @ [MOPED
nn o r� rod roMMIRr�a n 1 flf rIW G -•7 1 -h'� S
n -
/R a Ct�3�7 X .0.. REV now 1 1 dOf� E VG( N[
TITLE: ' ° ° D JS.0 �T)0O DE (D gE a
/ /
PERMIT #
DATE PAID 6)U o ®0 3
FEE PAID $ - - 00
RECEIPT # 7 47 ?
S QO IO
] INCHES
71 1E SU iC TANK SHALL, UE PUMPED GK )
1�'.f.J
..L.t..._.. . ^ _ ,
Applicant
• Zr EXP DATE:
CHD
Page 1 --of 2,
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:
DRAINFIELD:
OTHER:
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
EXPIRATION DATE:
Minimum specifications from Chapter 1OD -6, FAC.
Minimum specifications from Chapter 10D -6, FAC.
Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
Name of individual providing specifications. If designed by a registered engineer must be sealed.
County Health Department personnel reviewing and approving permit.
Date permit is issued by County Health Department.
One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the
date issued.
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION ERMIT
Permit Application Number MX 003
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes: OD
A9 %14
Site Plan submitted
Plan Approved
SIGNATURE
Not Approved
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SC
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14 116
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Date
ALL CHANGES MUST BEAPPROVED BY THE COUNTY PUBLIC HEALTH UNIT
HRS-H Form 4015,, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744.002 - 4015.61_
County Public Unit.
Page 2 of 3