SEPTICDate Job Address
Owner's Address SS ,JLO ?E5 S%
Square Ft . 2 ®0 jl)
Signature of owner and /or Condo President
Date: 04(7 4 y
Notary as to Owner and qt. P KC on � d�a ` rlgga OTARY SEAL
. 2 1 n MI DAMS
My Commission Expires. x * COMMISSION NUMBER
�'1II` a CC255237
7 .s 'y"' c.0 MY COMMISSION EXP.
APPROVED:
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
O F Ai�1 1997
Estimated Cost(value)
Fire
Zoning Buildin
Mechanical Plumbin
Tax Folio
Legal Description
Owner / Lessee / Tenant �� 1 Master Permit # ?([71)2.
Notary as to Cor
My Commission Er
Phone
Contracting Co. R20 Address C002 5(-- 3SCT ,' 11iz -- v i z
Qualifier A[- AN5-0-(.- Mv4- 0 1 SS# Phone � 1 ( -(CD 0 2 3 (
State # Municipal OP Competency # Ins.Co.
Architect /Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type(circle one): BUILDING ELECTRICAL PLUMBIN MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION ��`A -4
f,OO, o
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
aut h - the above -named contractor to do the work stated
Signature of Contractor or O r- Builder
Date: �(Zti 4
t 8V oQ Foftet e b�tlr1d tt. W DAVIS
4.A r * COMMISSION NUMBER
-1 _ .• I' Q CC255237
T R a? my COMMISSION EXP.
k of r- • 26 1997 *1
FEES: PERMIT -- RADON C.C.F. /OD NOTARY -- TOTAL DUE
Other
Electrical
t igineering
APPLICATION FOR:
( 1 New System ( ] Existing System [ ] Holding Tank .( ] Temporary /Experimental
(X ] Repair [ ) Abandonment [ ] Other(Specify)
APPLICANT:
po,t. g
MAILING ADDRESS: / 2 7 C T
AGENT:
r.
.p
LL
ssaea=s s = =sass= sec== == = == s = ==s = = == == s s m s s = == = == =ass =
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.
==i11=== ===- sOC =e == 9= = === = = == =sec ■=a= = - -111M - ass= = =iit= i==-= =sss = =sC-= Stts3ilM ==
=sss=
PROPERTY INFORMATION (IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: BLOCK: SUBDIVISION:
PROPERTY ID /:
PROPERTY SIZE: ACRES [Sgft /43560]
PROPERTY STREET ADDRESS:
DIRECTIONS TO PROPERTY:
BUILDING INFORMATION
Unit Type of No. of
][o pstablish:aent Bedrooms
2
3
4
( ] Garbage Grinders /Disposals
( ) Ultra -low Volume Flush Toilets
APPLICANT'S SIGNATURE:
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
()(1 RESIDENTIAL
(
1(00
NRS-N form 4015, Ner 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744.001- 4015-1)
) COMMERCIAL
Building $ Persons
Area Soft Served
PERMIT rR
DATE PAID
FEE PAID $
RECEIPT #
yv2
•
r.n. Y(, etr n C f l . 3 `•3 -) Z;
4/6 0
�9' fig
TELEPHONE: (R c ( n Cj ( r
DATE OF
S) In n 4 S SUBDIVISION:
[section /Township /Range /Parcel No.] ZONING:
PROPERTY WATER SUPPLY: [ 1 PRIVATE ( ) PUBLIC
Business Activity
}nor Commercial Only
[ ] spas /Hot Tubs ( ] Floor /Equipment Drains
[ ] Other (Specify)
DATE: V..) /s y
Page 1 of 3
CONSTRUCTION PERMIT FOR:
[ ] New System [ ] Existing System [ j Holding Tank / j Temporary/Experimental
(J Repair [ J Abandonment ( ] Other(Specify)
APPLICANT: S-='
PROPERTY STREET ADDRESS: ,� r I i t p µ s r
LOT: BLOCK: SUBDIVISION:
PROPERTY ID #: ,i/ , t( _ ,•.� ( SECTION /TOWSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 10D -6, F
REPAIR PERMITS AND HOLDING TANK PERMITS EXPIRE 90 DAYS FROM THE DATE OF ISSUE. ALL OTHER PERMI
EXPIRE ONE YEAR FROM THE DATE OF ISSUE. HRS APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTOR
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. SU
MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
a = s a
SYSTEM AND SPECIFICATIONS
T [it , / r] [GALLONS / GPD] SEPTIC TANK /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[
A ( 3 (GALLONS / GPD) CAPACITY MULTI- CHAMBERED /IN SERIES:(
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY (MAXIMUM CAPACITY SINGLE TANK: 1250 GALLON
IC [ ] GALLONS PER DOSE DOSING TANK CAPACITY DOSE RATE ( ] PER 24 HRS NO. OF PUMPS:
D (2.r SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ i . 0 0 1 # STANDARD [ ] FILLED [ ] MOUND ( )
I CONFIGURATION: [ ] TRENCH [..-.4 BED ( j
N
F LbCATION OF BENCHMARK: /J 14
I ELEVATION OF PROPOSED SYSTEM SIT . [ 9/, ) (INCHES /FT] (ABOVE /BELOW) BENCHMARK /REFERENCE POIZ
E BOTTOM OF DRAINFIELD TO BE ( 44 ] [INCHES /FT) [ABOVE /BELOW) BENCHMARK /REFERENCE POI/
L
D FILL REQUIRED: [f.JJ, ] INCHES EXCAVATION REQUIRED: ( 1 INCHES
0
T
H
E
R
fi 'r ';a;i$ I. '" •.
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
STATE OF FLORIDA REHABILITATIVE SERVICES
DEPARTMENT OF HEALTH AND
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: chapter 381, FS & Chapter lop-
6 ?AC
L04 S I I I/ ) 2 " fi w ci (/ti /4-e to o17 01 ra.;, f iid el re,.
5/z/14
TITLE:
HRS-H Form 4016, Mar 92 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016-0)
PERMIT #
DATE PAID
FEE PAID $
RECEIPT #
TITLES
EXPIRATION DATE:
AGENT: 4// p V T„.")00-4.e.
CPH
Page 1 of
By
Notes:
Plan Approved
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Iv ..
Permit Application Number V7
Site Plan submitted by:
PART II - SITE PLAN
•A• tt ••••, nna%i ne'N. ae!)
( 5fte I
4.).--1.) (-18
Not Approved
;L ( t)-
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
Ad aft
Date 43 1 2 / i
b (I 6 County Public Uni
_