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1290 NE 101 St (6)Date Legal Description Owner/Lessee / Tenant , MM ' �l 1 0 Bra Master Permit # 43/0 Owner's Address /216 101 -`h Phone Contracting Co. M/(. C Address l 9 3 2 1 J t•J - Z 4 - Qualifier SS# - 3.0r CS/ - 761 Cl k e- 6nlu State # r1 ' Municipal # Oa d, . Competency # Ins. Co. ;s,, G) / Architect/Engineer Address Bonding Company Address Mortgagor Address Permit Type (circle one): BUILDING PLUMBING MECHANICAL ROOFING WORK DESCRIP'T'ION 3t1 Square Ft Nib 2 PERMIT APPLICATION FOR MIAMI SHORES VILLAGE J o b Address 1 Mb b l C ` fa r S Folio 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. Notary Public Notary My Commission E . 6DAV■c . ) 4 / q Si esrdent Date • STEPHEN E COCKING my Comm. Exp: State of Florida D4 /0' FEES: PERMi3 RADON ELECTRICAL APPROVED: Zoning Building Mechanical Plumbing Historically Designated: Yes No Estimated Cost (value) )o co Signatur ( N. ary My Co of Contractor Sr Owner - Builder — 7 as s .�n > �• �'f ►M:.' 1 ` i� -r C.C.F. r 0 NOTARY g'A414VI iIC STATE OF FLORIDA Electrical / PAVING FENCE SIGN GLADYS J VILLAr NOTARY PUBLIC STATE OF FLORIDA COMMISSION NO. CCJ7141k3 MY COMMIS ON EX P. MAR. 1 2.r,ir Date A-o r, z /0 - /3 --7g Date BOND o v TOTAL l w Engineering APPLICANT: CONTRACTOR / AGENT: LOT: - BLOCK: - SUBDIV: 1 � - ✓ 2 6 s � _ - e ) TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS COMPLETE TANK CERTIFICATION BELOW OR ATTACH LETTER FROM A PERMITTED SEPTAGE DISPOSAL SERVICE. EXISTING TANK INFORMATION ['0 J D ] GALLONS SEPTIC TANK /GPD ATU [ ] GALLONS SEPTIC TANK /GPD ATU ].GALLONg'GREASE INTERCEPTOR ] GALLONS DOSING TANK [ [ I CERTI STRU ' • `LY SOUND, AND HAVE SOLIDS D. ' _ �/ /ICON D SIGNATURE OF L CENSED CONTRACTOR EXISTING DRAINFIELD INFORMATION (5 ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM [ ] SQUARE FEET / / SYSTEM TYPE OF SYSTEM: [M STANDARD ['" / FILLED [ CONFIGURATION: [ ] TRENCH [ ] BED [ DESIGN: [ ] HEADER [ ] D -BOX [./f GRAVITY SYSTEM ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE SYSTEM FAILURE AND REPAIR INFORMATION ] SITE CONDITIONS: NATURE OF FAILURE: FAILURE SYMPTOM: REMARKS /ADD SUBMITTED BY: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION T THE ABOVE NOTED TANKS WERE PU2$ED ON SYSTEM INSTALLATION DATE GPD ESTIMATED SEWAGE FLOW BASED [ ] DRAINAGE STRUCTURES [ ] POOL ( ] SLOPING PROPERTY [ ] [ ] HYDRAULIC OVERLOAD [ ] $OILS [ ] DRAINAGE / RUN OM I ] SEWAGE ON GROUND [ ] PLUMBING BACKUP [ ] TIONAL CRITER BUSINESS NAME DH 4015, 10/96 (Previous Editions may be used) LEGEND: MATERIAL: C 7C t LEGEND: MATERIAL: LEGEND: ,MATERIAL: LEGEND: "P NO. OF TRENCHES NO. OF TRENCHES ] 14 [ ] ] / 3 � HAVE THE VOLUMES SPECIFIED, I OUTL [ ] [ ] OF WASTE [ ] DOMESTIC ( ] COMMERCIL ] METERED WATER [ ] TABLE 1, 64E -6, Fi [ ] PATIO / DECK [ ] PARKING [ ] MAINTENANCE [ ] SYSTEM DAMAGE [ ] OOT [ ] WATER TABLE TITLE /LICENSE ] D BOX /HEADER PERMIT # FILTER EVICE ] INS AL ED. DIMENSIONS: DIMENSIONS: [ ] DOSED SYSTEM , NCHE ( ABOVE / E [ ] DRAINFIELD . ID# J/ 3 7a "K O& BAFFLED: BAFFLED: DAT Y../ # PUMPS: [ DATE: X X page 4 c NS 11tUCTIONS: 'ERMIT # D # ■PPLICANT ;ONTRACTOR/AGENT .OT,BLOCK,SUBDIVISION 3XISTING TANK. • TANK 1 TANK 2 3REASE INTERCEPTOR DOSING TANK TANK CERTIFICATION 0 3XISTING DRAINFIELD FIELD 1 FIELD 2 TYPE OF SYSTEM .3ONFIGURATION )ESIGN 3LEVATION TYPE OF WASTE 3PD FAILURE / REPAIR INFORMATION NSTALLATION DATE SITE CONDITIONS >IATURE OF FAILURE FAILURE SYMPTOM 1EMARKS SUBMITTED BY fITLE/L.ICENSE )ATE Permit tracking number assigned by department Property owner's full name Licensed contractor or property owner's legal agent Legal description for property Property appraiser identification number for property Complete tank size in gallons or gpd and mark appropriately. Complete LEGEND (SHO approval number),'MATERIAL (concrete, fiberglass, polyethylene) and whether or not tank in BAFFLED. Same as TANK 1. Same as TANK 1. Same as TANK 1. Complete # PUMPS installed. Completed by or letter attached fro itrpennitted septage disposal service puhp'inz tank. Complete size of drainfield in square feet, NO. OF TRENCHES (if applicable) and DIMENSION (bed width and length or trench width and total length of trenches). Same as FIELD 1 Mark appropriate block Mark appropriate block Mark appropriate blocks Record elevation of lowest point of bottom of drainfield in reference to natural grade Record year of originalsystem installation Mark appropriate block Provide estimated sewage flow to system based on metered water flow data (if available) or Table 1, whichever is greater. Mark all applicable blocks. Record any other significant conditions. Mark allopplicable blocks. Mark all applicable blocks. Record any other significant criteria that may impact system design. Signature of person performing evaluation Title of department person or license number of other evaluators. Date of evaluation. APPLICATION FOR: [ ] New. System [14 Existing System [ ] Holding Tank [ ] Innovative [ ] Repair [ ] Abandonment [ ] Temporary [ ) APPLICANT: SIC 44 �J(fl,c /4 C ( heriG ■• L • MAILING ADDRESS: 720% (0__1 z ' j 4 ' � g. 31)6y • AGENT: TO BE COMPLETED BY APPLICANT OR P.PPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. IT IS THE APPLICANT'S RESPONSIBIIAITY TO PROVIDE DOCUMENTATION'OP THE,DATE THE LOT WAS CREATED OR PLATTED (MM /DD /YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION LOT: PROPERTY ID #: // 3Z € C) /' -000 /32! PROPERTY SIZE: ACRE WATER SUPPLY: ( ] PRIVATE PUBLIC [p/f<= 2000GPD [ ] >2000GPD IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y /0] DISTANCE TO SEWER: / 296 "/E. (D/ DIRECTIONS TO PROPERTY: /1/-6 ft j r A/ t', 1 a,„ f\J-i[ t tI . /pl S/ 4 ,Itnr t"/ PROPERTY ADDRESS: BUILDING INFORMATION [V ] 'RESIDENTIAL [ I COMMERCIAL Unit Type of No. of Building Commercial /Institutional System Design No Establishment Bedrooms Area Sqft Table 1, Chapter 64E -6, FAC • 1 2 4 STATE OF FLORIDA PERMIT NO. DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #: APPLICATION FOR CONSTRUCTION PERMIT BLOCK: SUBDIVISION: 3'Pi ti/ gi b [ ] Floor /Equipment Dra'ns [ ) Other (Specify) SIGNATURE: DATE: DU 4015, 10/97 (Previous Editions May Be Used) 60/CD0,3 r/tAch-• TELEPHONE: 3os- 6 - , PLATTED: /9.5 ZONING: I/M OR EQUIVALENT: [ Y / N ] FT Page 1 or c LOT, BLOCK, SUBDIVISION: DATE OF SUBDIVISION: PROPERTY ID #: ZONING: PROPERTY SIZE: APPLICATION FOR: APPLICANT: AGENT: TELEPHONE: MAILING ADDRESS: WATER SUPPLY: SEWER AVAILABILITY: PROPERTY ADDRESS: DIRECTIONS: BUILDING INFORMATION: TYPE ESTABLISHMENT: NO. BEDROOMS: BUILDING AREA: BUSINESS ACTIVITY: FIXTURES: SIGNATURE / DATE: Check type of permit, if "Other" specify type in blank. Property owner's full name. Property owner's legally authorized representative. Telephone number for applicant or agent. P.O. box or street, city, state and zip code mailing address for applicant or agent. Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a recorded subdivision, a copy of the lot legal description or deed.must be attached. Official date of subdivision. recorded in county ghat books nontti/da t/y ) or date lot originally recorded. Dividigg an approved lot into two ormore parcels for the purpose of conveying ownership shall.be considered a subdivision of the lot. 27 character number for property. CH6 may ; require.property'appraiser ID # or section/township /range/parcel number. Specify zoning and whether or not property is in I/M zoning or equivalent usage. Net usable area of property in acres (square footage divided by 43,560 square feet) exclusive of all paved areas and prepared road beds within public rights -of way or easements and exclusive of streams, lakes, normally wet drainage ditches, rna(shes, or other such bodies o'Water. Contiguous unpaved. and non - compacted road rights -of -way and easements with no subsurface obstructions may be included in calculating lot area. Check private or public <= 2000 gallons per day or public > 2000 gallons per day. Is sewer available as per 381.0065, Florida Statutes, and distance to sewer in feet. Street address for property. For lots without an assigned street address, indicate street or road and locale in county. Provide detailed instructions to lot or attach an area map showing lot location. Check residential or commercial.. List type of establishment from Table II, Chapter 64E -6, FAC. Examples: single family, single wide mobile home, restaurant, doctor's office. Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations forrccupants. Total square footage of enclosed habitable area of dwelling unit, excluding garage, carport, exterior storage shed, or open or fully screened patios or decks: Based on outside measurements for each story of structure. For commercial/institutional applications only. List number of employees, shifts, and hours of operation, or other information required by Table II, Chapter 64E-6, FAC. - Mark FloodEquipment Drains or Others and specify item or "NA" if not applicable. Signature of applicant or agent. Dale application submitted to the CHD with appropriate fees and attachments. • ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or buildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope of property, any existing or proposed wells, drainage features, filled areas, obstructed areas, and surface water. Location of wells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent property, if the features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residences, a floor plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, a floor plan showing the square footage of the establishment, all plumbing drains and fixture types, and other features necessary to determine composition and quantity of wastewater. • •••••• , mi• i - 11 - riTHT • , T_F. TTrn- .IC Ti i --' 11 . , mum MANN NNE ' I NUS NEM • ri IN M M samme li _ ri --r all mum ow li t i LIT • • • _i__ _ Fi 1 it --' _.4 _+._ UM WI • • _ R ELIALEr . _, . MENU I E r . - - • , • UN M El no .__ - • -4-4 -- 1 - 7 ■ .4 - - -I_ Ern. , I T - t \ 1 7f7 1 • - 1 1: , -- - 1 + 1 ' ' 3 T. i- J--,- - 11 1111 611131 aammaam SIISEME•IMIN•NE 1111:11111110 OM II IIIIIii m•a•• am MENEM* MUM • I I I - --1- -74: , ! -t • T t---1-- 4- L . I-- --, 4 4 a . T r 4- , m40 f 1 - 1 -4- 1 - t - i -- - - - - . ' - i - - - . J_J t4 . f -- -1 - 9 1 _.. , 4.. i .1 , immal i -. , , - r [ t -1 ' T t - . /11111 4-,-,:___ i .: SEEM 111 1 I EMMEN MUM ! , MENNE IIN MONOMER WINIU ' ' IIIIII NOMMEN 2 ili ma _ • no • E ESS i 411 EN mommannummi.m ANNEENNEMENNEN ammon* EMEMENE SEMENNO MENNE MENSES MMENNEMEN EM MA II ENIII MENEM m num _, __ . . i am I Us MEMEIMI' MENO • inn MII MESE" _ . . O ••• ' • _ EN I -- MOUJIIIIE AVE ME MEMOS_ IMEENEES NONNI MEM E MENOMONEE' i EMMEN mom EMMEN SEMENNE : :pr ' ME MN • Us a , ! : _.„.., _ I-- mar smommas 1 , I _ BENNE SEEMS al Isli mmumalamonmommoassal SEM maammga ••ammiamaaam••• SEEMENSM •a••iam IIIIIIIIIIII ENNImmEMEN MEEEMMEEME 1111 IINEEMENES MEN IIIINNUE ammo MEM inmain ENSEMESS mgmaam IN a — NE M ENE . NI= ,- 4 4- 1_ --/-1-4 4 - 1 :III "Ma - - • - 4 - . - I $- -t 1 OM -* momman ESN= mom MONROE mmum • • is M - 4 Na • --' I. "f 1101 UM MEMNON A • _ . ao a RU ?-+ I /7) , •EMEN•MEN a pa alga TTT NORM laugg i ENESE ram Nall me NAC:m" 1 • im NOMMAI mawn m _ I I IIII Ili IIIIIIIIIAIIIIIIIREP MM III M • d IIIIIII ' 11111121 1 04SUII I NNIIIIII IIII i NOME MEE IMINMEINEM ri, W I I II I ° AIL. 1 EN M MN M l eIIIIII II A N ' 111ZollEMAr -1 •1141 1111111 III0111111 IMENNE SAIN ' e Li NE Ilium iiinniams salilihm. mummy own is oft= in 1 EMI il 1 = r IIIlll ammo iiiiiiIIIIIIIIii lim __mm ammarimmaanagam al 1 man MENEM= MENEMi maimmu magma mama maammagy mugs IIIIJIIIIIIII 11 anagammou 11111 moolir omommommomaammomma mamma mamma ma ommommaamm ma mom ammo STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT F Application Number Scale: Each block represents 5 fe t and 1 inch = 50 feet. Notes: C OH 4015. IMO (Replaces HRS-H Form 4015 which may be used) (Stock Number: 5744-002-4015-6) PART II - SITE PLAN- e) 7/3/03. ,v7c/41 Atal e 14 gna Not Approved Site Plan submitted by: Plan Approved By County Health Department ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT lit Date Page 2 of 3 APPLICANT: LOT: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS ,3 M fi AGENT: � . C PERMIT # 4 4 t BLOCK: SUBDIVISION: _) r _ G� PROPERTY ID #: //_ 3' _ e/y _ alv. [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: ACRES TOTAL ESTIMATED SEWAGE FLOW: 5 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] AUTHORIZED SEWAGE FLOW: �(Jei GALLONS PER DAY (1500 GPD /ACRE OR 2500 GPD /ACRE] UNOBSTRUCTED AREA AVAILABLE: /�7) SQFT UNOBSTRUCTED AREA REQUIRED: rdi) SQFT SITE EVALUATED BY: DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3] which may be used) (Stock Number: 5744- 003 - 4015 -1) BENCHMARK /REFERENCE POINT LOCATION: ELEVATION OF PROPOSED SYSTEM SITE IS ' Z [INCH unsell olor Texture Depth to to 4w1-04014_ to t t to USDA SOIL SERIES: /44.i AA , o • ft 34 g 7 [ABO ENCHMARK/REFERENCE OIN THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURRE: / SURFACE WATER: 0 FT DITCHES /SWALES: / [ FT NORMALLY WET? [ ] YES NO WELLS: PUBLIC: /J/A FT LIMITED USE: FT PRIVATE: ,/gt_ FT NON - POTABLE: 7s FT BUILDING FOUNDATIONS: 9 FT PROPERT LINES: OS FT POTABLE WATER LINES: 73r FT SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [1/ 10 YEAR FLOODING? [ ] YES [ 44O 10 YEAR FLOOD ELEVATION FOR SITE: l FT MSL /NGVD SITE ELEVATION: 5 7 FT MSL /NGVD / 441- _ SOIL PROFILE INFORMATION SITE 1 /T �� j'J SOIL PROFILE INFORMATION SITE 2 Munsell Color Texture Depth AL /111. iy' �,� to Jz „ to to .p to to USDA SOIL SERIES: 2 O k [ ,1 OBSERVED WATER TABLE: /v it- INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT] ESTIMATED WET SEASON WA ER TABLE ELEVATI: INCHES [ ABOVE /BELOW ] EXISTING GRADE. HIGH WATER TABLE VEGETATION: [ ] YES [ NO MOTTLING: [ ] YES [ NO DEPTH: INCHES SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES DRAINFIELD CONFIGURATION: [ ] TRENCH [s�J BED [ ] OTHER (SPECIFY) REMARKS /ADDITIONAL CRITERIA: DATE: Page 3 of 3 INSTRUCTIONS: PERMIT NUMBER: Permit tracking number by County Health Department. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. a PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number). PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of ' all paved areas and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. SEWAGE FLOW: UNOBSTRUCTED AREA: MINIMUM SETBACKS: Record the estimated sewage flow for the establishment from Table I (residence) or Table 2 (non - residential), Chapter 10D-6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied. Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter 10D -6, FAC. The unobstructed area must be contiguous to the drainfield. BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual 'elevation. Record the elevation otthe proposed system site in relation (above or below) to the benchmark. Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or "NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured. The location of any public drinking well within 200 feet of the applicant's lot must also be verified. FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for site and actual site elevation. SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will use 'USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be determined. WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if. there is high water table vegetation present. Indicate if mottling is present and depth. SOIL TEXTURE: Record soil texture or loading rate for system sizing. DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable. DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type. ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required. SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted. ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS: BENCHMARK [ +]SHOT H.I. SITE 1 H.I. [ - ]SHOT SITE 2 H.I. [ - ]SHOT SITE 3 H.I. [ - ]SHOT STATE OF FLORIDA PERMIT NO. DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #: APPLICATION FOR CONSTRUCTION PERMIT PPLWCATION• FOR: g System ] New System ['. l Existin S stem [ ] Holding Tank. [ ] Innovative . [ ]. Repair [ ] Abandonment [ ] Temporary [ ] APPLICANT: ES16 4//A c fa Ac) ~ AGENT: i C S J1017 .- . J/r.. -. J Z C. ` TELEPHONE: j5--G�f ' .'$$7 . � �" � /• t, MAILING ADDRESS : 1: ''�' 6— 7 � Z'� ~ o 41`-k i-g 3 3l 61 • ` TO BE COMPLETED BY APPLICANT. OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON•LICSNSED PURSUANT TO 489.105(3)(m) OR 48'9.552, FLORIDA STATUTES. IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATIONreF THE,.ATE THE LOT WAS CREATED OR PLATTED (MM/DD /YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. - == PROPERTY INFORMATION LOT: BLOCK: —' SUBDIVISION: PROPERTY ID #: // � " Of'/ - oo/Z 3 PROPERTY SIZE: ACRE WATER SUPPLY: [ ] PRIVATE PUBLIC [104<= 2000GPD [ IS SEWER AVAILABLE AS PER 381.0065, FS? [ Y /0] DISTANCE TO SEWER: /29 ,,•16 (Di 331 3p NC. /Di dige4 .e �� PROPERTY ADDRESS: DIRECTIONS TO PROPERTY: BUILDING INFORMATION 2 4 SIGNATURE: RESIDENTIAL 6 S / 444,1 3 -- ZONING: I/M OR EQUIVALENT: [ Y / N] [ ] COMMERCIAL f r,e.~ 3 :`.v toff DATE: PLATTED: /9.5 ] >2000GPD A. FT Unit Type of No. of Building 'Commercial/Institutional System Design No Establishment Bedrooms Area Sqft Table 1, Chapter 64E -6, FAC [ ] Floor /Equipment Drans [ ] Other (Specify) Page 1 or DH 4015, 10/97 (Previous Editions May De Used) ;ale: Each block represents 5 fe t and 1 Inch = 50 feet. r „,,.........• 7 ....„.....,..... _.... ;•, T ..„........_ r ... 7 . . _• : ..•, .,, •• ....,.••..._, ..... _ ....i...... . I . _:_ ,.. ,.... .,-, .■••- i 4-.4- . -4 .; ;;;; ; . . i ... ._.,...: ,-4-.4 . , i;-;;;' ;4 4 . : 1; ...; • ' L-A. ; : , ; : ..' . ..1 i.. ! 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I ' 11.:1_ 1 .1_ .. .j. - --- _.._4......_ .! • I ..._ . _ 1- 4 ! lotes: D4s 6 STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number 14015, 10/98 (Replaces HRS44 Form 4015 which may be used) lock Number: 5744-002-401540 PART II - SITE PLAN- - • 1. s . 11 • _ • ! .1 1" . •1. " • -4-- ;.-- ••--1-•-i- -4-- r- .. T t 1 T • - r - _ , . . l• ...;;;;,•i• 4. 4; 4- L; ;;• ; ,; ;11 ;; • - •--1 -4-1 • ; 1, + ;4 1 4-; 4 i 1 4 -1---- 1---)-- , L44t • ' 1 4-- - -.1-' • ' -4--el • 1 , 1 -- („ • 't - t - t -- 4 - ± - 1 -- f ---- r - ; - ' - I i , . _. ,_._. 1 '1 - -1 . 1 - - 1_ -- Li - ... -4- '---. ri t , , 1 - 1„._ ----,. : -- H - - - L' .1. ' ' T J 1 r i , _..11a..,- . 2:.I . ..;: - 1 - I.- 1. site Plan submitted. by: 'Ian Approved ly County Health Department ALL CHANGES MUST Bt APPROVED BY THE COUNTY HEALTH DEPARTMENT . gna bre Not Approved : .: • .4 ; • •, .; „ .. • j ; • •.; ; 4 ;• ••, •• .1 ; • _ 1 • • f ! 4- ' : 1 -44 • + -4-. • - • -••■•••-'.- • ; • I" , -; sl• - 4 - • • 4-••-1--••-•• - 4••••. --• - . I ' " • 1 I , 7 Tit Date 7 is& Page 2 of 3 PPLICANT: DT: ROPERTY ID #://.. 31 ,' e,i /... 02)/2)- 0 BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST ROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. ROPERTY SIZE CONFORMS TO SITE PLAN: [ ] OTAL ESTIMATED SEWAGE FLOW: 5 UTHORIZED SEWAGE FLOW: P/,>2.— NOBSTRUCTED AREA AVAILABLE: /"D1.11) ENCHMARK /REFERENCE POINT LOCATION: -, -_ (-rAia LEVATION OF PROPOSED SYSTEM SITE IS ' Z.. [INCH HE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURE: URFACE WATER: / �9 FT DITCHES /SWALES: / r FT NORMALLY WET? [ ] YES ( N( ELLS: PUBLIC: /J /A FT LIMITED USE: — FT PRIVATE: 2gt_ FT NON- POTABLE: 7 F7 p UILDING FOUNDATIONS: I FT PROPERTY LINES: SS FT POTABLE WATER LINES: 7 S F7 ITE SUBJECT TO FREQUENT FLOODING: [ ] YES • [t4 10 YEAR FLOODING? [ ] YES [41( 0 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SITE ELEVATION: S 7 FT MSL /NGVI OIL PROFILE INFORMATION SITE 1 / 407 ?j'S ~ SOIL PROFILE INFORMATION SITE 2 rr . u.sell t / t0 USDA SOIL SERIES:Iii, ' 4 /_A r J ' ISSERVEI) WATER TABLE: p i --- INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT) [STIMATED WET SEASON WA E R TABLE ELEVATIO : INCHES [ ABOVE / BELOW ] EXISTING GRADE [IGH WATER TABLE VEGETATION: [ ] YES ( \NO MOTTLING: [ ] YES [ NO DEPTH: INCHE: SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHE: IRAINFIELD CONFIGURATION: [ ] TRENCH [ [ ] OTHER (SPECIFY) :EMARKS /ADDITIONAL CRITERIA: [ITE EVALUATED BY: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS 4 /34"/ cz- ivlr.,,1' AGENT: /' /�,� Cr I J BLOCK: - SUBDIVISION: /"'"2„ '/ � g [Section/Township/Range/Parcel No. or Tax ID Number) olor Texture Depth to to v to-77....' to to t )H 4015, 10196 (Replaces HRS -H Form 4015 [Page 3) which may be used) Stock Number: 5744- 003 - 4015 -1) YES [ ] NO NET USABLE AREA AVAILABLE: ,171,/ ACRE: GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2] GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE] SQFT UNOBSTRUCTED AREA REQUIRED: ref SQFI PERMIT # [ABO BEL•• =EN HMARK /REFERENCE POINT Munsell ;.Color Texture Depth . ' to �. USDA SOIL SERIES: W O & 2 4 6 to to t.. •p to to DATE: L 7 6 3-.� . GJ Page 3 of APPLICANT: CONTRACTOR / AGENT: LOT: BLOCK: SUBDIV: //- °I ISO p TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT, EMPLOYEE, SEPTIC TANK CONTRACTOR OR OTHER CERTIFIED PERSON, SIGN AND SEAL ALL SUBMITTED DOCUMENTS.. COMPLETE ALL APPLICABLE ITEMS COMPLETE TANK CERTIFICATION BELOW OR ATTACH LETTER FROM A PERMITTED SEPTAGE DISPOSAL SERVICE. EXISTING TANK INFORMATION VO J D ] GALLONS SEPTIC [ ] GALLONS SEPTIC [ ] GALLONS GREASE [ ] GALLONS DOSING _________ I CERTI STRU SITE CONDITIONS: NATURE OF FAILURE: FAILURE SYMPTOM: REMARKS /ADD SUBMITTED BY: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION LY SOUND, AND HA V4 cf2a,,,,I ____ _■■■__ TANK /GPD ATU TANK /GPD ATU INTERCEPTOR TANK SOLIDS D T THE ABOVE NOTED TANKS WERE SIGNATURE OF LICENSED CONTRACTOR == == EXISTING DRAINFIELD INFORMATION SYSTEM FAILURE AND REPAIR INFORMATION __= LEGEND: LEGEND: LEGEND: LEGEND: SYSTEM INSTALLATION DATE GPD ESTIMATED SEWAGE FLOW BASED BUSI SS NAME [ P ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM [ ] SQUARE FEET / SYSTEM TYPE OF SYSTEM: (ICI STANDARD [` FILLED [ CONFIGURATION: [ ] TRENCH [ ] BED [ DESIGN: [ ] HEADER [ ] D -BOX (-1 GRAVITY SYSTEM ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE [ ] DRAINAGE STRUCTURES [ ] POOL [ ] SLOPING PROPERTY [ ] SEWAGE ON GROUND [ ] PLUMBING BACKUP . [ [ ] HYDRAULIC OVERLOAD [ ] OILS [ ] DRAINAGE / RUN OF& [ , ] OOT [ ] TIONAL CRITER ,C) � =�� DH 4015, 10/96 (Previous Editions may be used) PERMIT # - = __ _ MATERIAL: MATERIAL: MATERIAL: •"MATERIAL: P I yr . P ON . , � / . 3 103, , HAVE THE VOLUMES SPECIFIED, A OUT F J/EVICE ] INS ED. NO. OF TRENCHES NO. OF TRENCHES ] M9 [ I TITLE /LICENSE [ ] [ ] ID# J/ 32a O /y-4 DIMENSIONS: DIMENSIONS: BAFFLED: BAFFLED : 'rt / # PUMPS:[ DAT [ ] PATIO / DECK [ ] PARKING [ ] D BOX /HEADER [ ] DRAINFIELD . =_ X X .,r [ ] DOSED SYSTEM 2 CHE [ ABOVE /` EL OF WASTE [ ] DOMESTIC '[ ] COMMERCI; ] METERED WATER [ ] TABLE 1, 64E -6, Fi [ ] MAINTENANCE [ ] SYSTEM DAMAGE [ ] WATER TABLE [ ] Page 4 c