1177 NE 100 St (13)i `N
i
I
DRAINFIELD INSTALLATION
[ ] [10] AREA [ 3[
[ ] [11] DISTRI ION BOX
[ ] [12] NUMBER OF DRAINLINES
[ ] [13] DRAINLINE SEPARATION
[ ] [14] DRAINLINE SLOPE
/ 1 1 [ ] [15) DEPTH OF COVER /? • '
/ a [ ] r 16 t EL EVATION (ABOVF"/ i BM 1/• [
APPLICANT:
A G E N T $ .S A V V G f 3 / 3
PROPERTY ADDRESS: 11 ; /V, h90
LOT: J3 BLOCK: SUBDIVISION: s - c1 - ( 1 -14:- Pia,__PROPERTY ID 0: 11
03$
====================
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITS STATU'T'E
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CONSTRUCTIO
FINAL 8YS
DH 4016, 10
STATE OF FLORIDA PERMIT NO.
DEPARTMENT OF HEALTH DATE PAID: 6 -- 2 y - rya
ONSITE SEWAGE TREATMENT AND DIPOSAL. SYSTEM FEE PAID:
CONSTRUCTION INSPECTION AND FINAL APPROVAL RECEIPT 1:
•
TANK INSTALLATION
[01]
[02]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
C ,
TANK 8I8E [4/ [2]
TANK MATERIAL _,,a [
OUTLET DEVICE ?.�� --- [
MULTI - CHAMBERED [(YJ/ N ] / [
OUTLET FILTER Z./9,6 e t - [
LEGEND ) , X / - 7. - 074 — V) [
WATERTIGHT � °� C [
_/
DEPTH TO LID 1
_ SQFT
HEADER
1
[
[
[17] SYSTEM LOCATION ,.....f . 1
[18) DOSING PUMPS JV l [
[ 19l AGGREGATE SIZEJ`_5 1.:.2,(2
[
[20] AGGREGATE EXCESSIVE FINES 'J [
[21] AGGREGATE DEPTH !,2 // [
[
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT ),z /1
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
(26) REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
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[ ]
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OR RULE AND MUST BE
SETBACKS
SURFACE WATER
DITCHES
PRIVATE WELLS
PUBLIC WELLS
[
[
[29]
[30]
[31]
[32]
[33.]
[34]
[35]
IRRIGATION WELLS /or)
PROPERTY LINES
OTHER
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
SAPPROVED] : X 1,''t- Uc ) 6, QC=
APPRO ' W r„ DISAPPROVED ] : XPJ''L4 C �c� 7
Previous Editions May Be Used)
PT 1: Applicant
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
CORRECTED.
7r;
FT
FT
FT
FT
POTABLE WATER LINES o2 S FT
BUILDING FOUNDATION / rw FT
FT
FT
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ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
(47] CONTRACTOR 21-6 C
(48) OTHER .
ABANDONMENT
[ 49 ] TANK PUe= J2 d 3 /'
(50) TANK CRUSHED & FILLED _/. S/ (
DATE :6 s - 03
DATE: ' ��" '{
Page 2 of 3
PERMIT NUMBER: Permit tracking number assigned by CHD.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION Lot, Block and Subdivision for lot or
PROPERTY ID#: 27 character number for property. (property appraiser ID # or GIS location)
COUNTY HEALTH DEPARTMENT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND
STATUTE OR RULE. INFORMATION IS COMPLETED BY CHD ON FOLLOWING ITEMS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
OUTLET FILTER (manufacturer, make, model)
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
DISTRIBUTION BOX / HEADER (check box)
NUMBER OF DRAINLINES (number installed)
SYSTEM ELEVATION (in relation to BM)
DOSING PUMPS (number installed)
SETBACKS (record actual setbacks in 11)
SETBACKS OTHER (as required)
STABILIZATION (date stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS: Record Item number, explanation of violation, and required
CONSTRUCTION APPROVAL: Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Cirde approved or disapproved. CHD signature and date of approval.
Final approval shall not be granted unit the CHD has confirmed that building construction and lot grading are in substantial
compliance with plans and specifications submitted with the permit application.
AS BUILT INSTALLATION SKETCH
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
EXISTING GROUND TOP OF AGGREGATE
[ +] SHOT H.I. H.I. H.I.
H.I. [ -] SHOT [ -] SHOT [ -] SHOT
ELEVATION
- --
CLOSETS
BATH
Tuna
SHOWERS
LAVA•
TORIES
SINI(t
SLOP
SINKS
LAUNDRY
Tune
URINALS
CATCH
SARIN
FLOOR
DRAIN
DRINK NO
FOUNT' NS
TOTAL
PI
CONTR.
LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
GRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
WATER
DEW
WELL
SPRKLR
S
SW IM'O
POOL
co. Nr11
LIST
35'
.
r�
CHECK
Size Septic Tank._
Foot of Drain Tile
Nature of Water Supply: City —Well.
Amount of Permit $ $4. 00
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
� .
Permit No �(, Date..__.__.. 7 - 77 _w
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Thomas Teas ley 1177 N.E. 10
Owners Name and Address No -_—
Registered Architect and /or Engineer
E uip)Pying plumbs'+ Name Rose Septic Tank _ Co ._.._ Na„�.., .�..,..... itr«e�.�....v. ::....�... �.._.,��..._
P.O.Box 344 Hialeah 3011
Location and Legal Description Lot- S lo e SubdivWon.__-_
Street and Number where work is to be performed —No
State work to be performed and purpose of building (By Floors)__.. __
New Building .___.___--- ._-____......___ Remodelling_______.___._ - -__ Addition
Type of Tank_
Dist Feet of Talc or Drain Field from Well
Size of Soakage Pit.
(Signed)_
--
(Signed)
Street.
Repairs_ No. of Stories
Capacity Cals.
Plumbing Inspector.
The undersigned applicant for this building permit does hereby certify that he understands and accepts his .f. ligation. as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5988, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub-contractors, on work to be performed under this permit, as are
licensed by Miami Shores Village.
•
Master Plumber.
STATE OF FLORIDA, µ
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that be has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
M Corami.,ice E Notary Public, State of Florida
NOTE: A re- inspection fee of =1.00 will be anode whoa mob re-leepaotioe is node•naoawary by ianproper notice for inspection, or faulty
materials and/or wadon.nahip.
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the build-
ing or other structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami
Shores Village, Florida, and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and
regulations of the Building Division of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved
plans and specifications must be kept at building during progress of the work.
Owner's Name and Address.... 9..e4A i S- - I
Registered Architect and /or Engineer
Name and address of licensed contractor
Disapproved Dat
(Signed)
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MIAMI SHORES VILLAGE
BUILDING INSPECTION DEPARTMENT
APPLICATION FOR BUILDING PERMIT
.atZ,TIF-..t )1 0
New Building Remodeling Addition
Date .. - a. ,
No. 11.q Street... 1st:. E. 1 Q_c?. -
(Signed )
Notary Public, State of Florida
Location and legal description of lot to be built on:
Lot Block Subdivision AA
Street and Number where work is to be done._ __ J _ - -_ 14- 1 0
State work to be done and purpose of building (by floors) / ta ®ice ,.
_ - - ?-3 `U- -�I � � r. and for no other purpose.
Repairs No. of Stories
To be constructed of Kind of foundation Roof Covering
Estimated Total cost of improvements $ ...1 Amount of Permit $
Zone cubage required _Plan Cubage
Distance to next nearest building Size of Building Lot
Maximum live load to be borne by each floor
I hereby submit all the plans and specifica ion for said building. All; otices with reference to the building and its construction may
be sent to 4_�__i, 4
The undersigned applicant for this building permit does hereby certify that he u nderstands and accepts his obligations as an employer
of labor under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida, Permanent Supplement,
and has complied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him
in the work to be performed under this permit; and will post or cause to be posted for inspection on the site of the work such public notice
or notices as are required by the Act. The undersigned agrees to employ only suck subcontractors, on work to be performed under this
permit, as are licensed by Miami Shores Village.
Remarks
STATE OF FLORIDA, 1
COUNTY OF DADE. j ss'
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, perscJl'ally ap-
peared
- -• to me well known,
and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
Permit No �_.3 Date ° 5-0 Read, Sworn to and Subscribed before me.
Buildii nspector My Commission Expires
PLANNING BOARD DATE
Chainnan Member
Member Member
Member ... Member
Council Approved Date Disapproved Date
NOTE: A charge of $1.00 will be made for making corrections or changes to this application after approval has been obtained from
the Planning Board.
A re- inspection fee of $1.00 will be charged when such re- inspection is made necessary by improper notice for inspection or faulty
materials and /or workmanship.
Permit No. _a___
(
Amount of Permit $ A-
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address +'_ - No Street
,Registered Architect and /or Engineer
59 Employing Plumber's Name �c=-- I- C.o�.�`� No Street
State work to be performed and purpose of building (By Floors)
Location and Legal Description Lot / 3 - Block /
Street and Number where work is to be performed— No. ___ /2 2 _ _ t"
(Signed)
7 7
Street
Subdivision '! S: �
Date
New Building Remodeling Addition Repairs No. of Stories
Size Septic Tank Type of Tank Capacity Gals a
My Commission Expires Notary Public, State of Florida
Feet of Drain Tile /0 o Dist. Feet of Tank or Drain Field from Well U
Nature of Water Supply: City —Well Size of Soakage Pit
�c 11imbing Inspector.
The undersigned applicant for this building permit does hereby certify that un erstands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
perfornned under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on rvor o be performed under this permit, as are
licensed by Miami Shores Village.
(Signed)
Master Plumber.
STATE OF FLORIDA, 1
ss.
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.
CLOSETS
BATH
TUBS
SHOWERS
LAVA
TORIES
SINKS
SLOP
SINKS
LAUNDRY
TUBS
URINALS
CATCH
BASIN
FLOOR
DRAIN
DRINKING
FOUNT' NS
TOTAL
FIXTURES
CONTR.
' LIST
CHECK
SEPTIC
TANK
SEWER
CONN.
DRAIN
FIELD
SOAKAGE
PIT
GREASE
TRAP
SOLAR
HEATER
DEEP
WELL
SPRKLR.
SYSTEM
SW IM'G
POOL
CONTR.
LIST
CHECK
•
Permit No. _a___
(
Amount of Permit $ A-
MIAMI SHORES VILLAGE
PLUMBING INSPECTION DEPARTMENT
APPLICATION FOR PLUMBING PERMIT
Application is hereby made for the approval of the detailed statement of the plans and specifications herewith submitted for the building or other
structure herein described. This application is made in compliance and conformity with the Building Ordinance of Miami Shores Village, Florida,
and all provisions of the Laws of the State of Florida, all ordinances of Miami Shores Village and all rules and regulations of the Building Division
of Miami Shores Village shall be complied with, whether herein specified or not. A copy of approved plans and specifications must be kept at
building during progress of work.
Owner's Name and Address +'_ - No Street
,Registered Architect and /or Engineer
59 Employing Plumber's Name �c=-- I- C.o�.�`� No Street
State work to be performed and purpose of building (By Floors)
Location and Legal Description Lot / 3 - Block /
Street and Number where work is to be performed— No. ___ /2 2 _ _ t"
(Signed)
7 7
Street
Subdivision '! S: �
Date
New Building Remodeling Addition Repairs No. of Stories
Size Septic Tank Type of Tank Capacity Gals a
My Commission Expires Notary Public, State of Florida
Feet of Drain Tile /0 o Dist. Feet of Tank or Drain Field from Well U
Nature of Water Supply: City —Well Size of Soakage Pit
�c 11imbing Inspector.
The undersigned applicant for this building permit does hereby certify that un erstands and accepts his obligations as an employer of labor
under the Florida Workmen's Compensation Act, being Section 5966, Compiled General Laws of Florida Permanent Supplement, and has com-
plied with the provisions thereof, and will require similar compliance from all contractors or sub - contractors employed by him in the work to be
perfornned under this permit; and will post or cause to be posted for inspection on the site of the work such public notice or notices as are
required by the Act. The undersigned agrees to employ only such sub - contractors, on rvor o be performed under this permit, as are
licensed by Miami Shores Village.
(Signed)
Master Plumber.
STATE OF FLORIDA, 1
ss.
COUNTY OF DADE.
Before me, the undersigned authority, a notary public, duly authorized to administer oaths and take acknowledgments, personally appeared
to me well known, and who, being by me first duly sworn, upon oath deposes and says that he is the
of the above described construction, that he has carefully read the foregoing application, and that he did sign the same, and that all facts
therein by him stated are true.
NOTE: A re- inspection fee of $1.00 will be made when such re- inspection is made necessary by improper notice for inspection, or faulty
materials and /or workmanship.