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DRAINFIELDPERMIT APPLICATION FOR MIAMI SHORES VILLAGE Date 7 / 2 0 9 99 Job Address 4 40 € . ( p dr 5 7 Tax Folio Legal Description Historically Designated: Yes " �/ Li 0 Owner/Lessee / Tenant t /4 �i , / �eS1 U Master Permit # ( S / 8 C I Owner's Address ( CD A/6 (Gl" - 4e Phone( 5J Y q q ' z Co. NA. C � �T �' � / � � Address /777 Qualifier O& P/-/ t':"/ C • ( t43 „lc/ 7 . Phone o 'y' - 651' 7 e,.s.? 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 / I �� r> �0J �r7d - Square Ft 3.4C0 Estimated Cost (value) /itaCI 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 and zoning. Furthermore, I authorize the above -named contractor to do the work stated. ature of own and/or Condo President Date bL S5S3 i7 -2/3 -© s Notary as to Oxviw Date Notary as to Contractor or Owner- Builder My Conunission€ t h d ;°° i12 i s c)Nl 3O3 3 N3Hd31S FEES: PERMIT SS" RADON APPROVED: Zoning Mechanical Plumbing C.C.F. Signature of Contractor or Owner- Builder My Commission Expires: 7/ 2- e 9/ (Date Date NOTARY BOND TOTAL DUE Building n Electrical Engineering LOT: _ BLOCK: SUBDIVISION: PROPERTY ID #:�� STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Authority: Chapter 381, FS & Chapter 10D -6, FAC PERMIT # DATE PAID 7- z7 FEE PAID $ sj RECEIPT # COIISTRUCTION PERMIT FOR: ] New System Ri y Existing System ( Holding Tank FL.4 Temporary /Experimental ( ] Repair ] Abandonment ] Other(Specify) APPLICANT: 2 , ' ' J �� � � / AGENT: 11„� s PROPERTY STREET ADDRESS: /+ ® A c_m [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. 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 SPECIFICATIONS r T fao L[GALLOf'§ / G SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI - CHAMBERED /IN SERIES:[ ] A [ ] [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: [ ] D O o: 6QUAR FEET PRIM ST ARY D SY R E R [ ] SQUARE FEET �/ SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [./I BED [ [ N �. / po ( �rj� F LOCATION OF BENCHMARK :/0. A ' � 1) D F /,'Grl re, 00 4/; �•I I ELEVATION OF PROPOSED SYSTEM SITE [_C ) KIINCHE'SJ FT] [ABOV BELO' BENCHMA INCHJFT] [ABOKETEELD72, BENCHMAR E BOTTOM OF DRAINFIELD TO BE [ [j) L D FILL REQUIRED: [ ] INCHES . _ 0 T H E SPECIFICATIONS BY: APPROVED BY: DATE ISSUED ; EXCAVATION REQUIRED: [ 3 ] INCHES TITLE: TITLE. HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) (Stock Number: 5744- 001 - 4016 -0) G.1PPLO©ART REFEREN REFERENCE PO CPHU EXPIRATION DATE: - Page 1 of 2 Scale: Each block represents 5 feet and 1 inch = 50 feet. I .I [ � � _ - _ - - -- hr 11 !!� L I._ r ' I .I_' 4 1 IL I 1 — fj 1 1 1 1 — i H -! 1 I ;4 . 1 ._ i I 1 " J 1I1I i1 1 -1 1 1 II I r' 1 [-1 I `� LJ_1_I - I_,\ i l t 1 J =f_ L h i i !_ _. L.— _ JJ ] I I _ I I }} i� II I_1_ I I -1 '1 1 �I _ III I _ I - 1 1 =i r I ( L .1_,I_ . tff IJ__I 1 + I J 1.__I .1_ _ I. 1- 1-1- ( ._ _ - _-!_ l - L.-J I -� IJ -u_ �.1LL _ i i _1 I_ i� 1 1 ! L LL 1 _ I _ 1 _ 1 1- _fT1_': _._t_ - _ 1 1 J. _1_ 1. , - L J C _�'.�I _ 1 1 l_ , _.r _ - . 1 �_ I r 1 Ll � _ (! 1 I _ I IJ—LI _ I I II_ — __ I. I 1 J I- E , _ 1 1 1 LI I� -b CU ❑ ;Li 1 1 Notes: Site Plan submit b f: Plan Approved By STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER Permit Application Number / r - • ALL CHANGES MUST BE APPR 1 DH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used) (Stock Number: 5744 -002- 4015 -6) PART II - SITE PLAN Signature Not Approved . V. t Date 7 2 -/ � County Health Depa BY THE COUNTY HEALTH DEPARTMENT Page 2 of 3 BUILDING ❑ ELECTRICAL ❑ PLUMBING ❑ RopFING ❑ Owner of Building Architect Contractor or Builder Legal Description Address of Building 'Y. -J.(.::" Lot MIAMI SHORES VILLAGE. FLORIDA • / � / • PERMIT N° Bl Work to be performed under this Permit 7173 _ Value of Project $ 195 DATE Contractor's License No; i 5 Subdi- vision Amount of / s Permit $ , 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 application herefor in strict compliance with all ordinances pertaining thereto and with 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 assumes the responsibility for a thorough knowledge of the ordinances and regulations pertaining to the work covered hereby whether shown on the plans or drawings or in the statements or specificati s and that he assumes responsibility for work done by his agents, servants or employees. Signed J 1 �, d BY• ""� ' ° INSPECTOR In consideration of the issuance to me of this permit I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In ac- cepting this permit I assume responsibility for all work done by either, myself, my agent, servant or e ployee. , C CONTRACTOR OR BUILDER BY AUTHORITY 6 4.