DRAINFIELD 1998Date 9 - / /- le Job Address 13 111 t Tax Folio
Legal Description
Owner/Lessee / Tenant Ci\D
Owner's Address 564■44.-
Contracting Co.
Qualifier tJ dilvv �
State # Municipal # ,5fp 000 atir Competency #
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL PLUMBIN MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION �, S 6 � Of cJ
Square Ft. 3OC.)
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 m compliance with all applicable
laws regulating construction and zoning. Furthermore, I authorize the above -named contractor to do the work
q/i (ITY
Signature /owner and/or Condo President Date 2003
Atio
No . to O
My ommission Expires: GLADYS 1 VILLAR
NOTARY PUBLIC STATE OF FLORIDA
COMMISSION NO..CC714103
MY� ION EXP. MAR.
FEES: PERMIT , ? C.C.F.
APPROVED:
Zoning Building
Mechanical
PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
-- - Ma,r kfL
9 - / / -C'
Historically Designated: Yes No
Master Permit # 5'61--e, : c ,32
Phone 3
Address f&O0Z.2 S w' 42
-
Estimated Cost (value`
Signature of Contrac
Electrical
Ins. Co.
CfZret—yiNc
Date
1.11 i, 'ft,�. ( 5 —/7 —
Notary as to Contractor or Owner - Builder Date
My Commission Expires:
, t S;Y Pp Wm. MARK WOODARD
ct, COMMISSION # CC 625712
Q EXPIRES MA R 2, 2001
►�` 0 BONDED THRU
OF F"$ ATLANTIC BONDING CO., INC.
NOTARY 5 / BOND 300
TOTAL DUE
Engineering
CONSTRUCTION PERMIT FQR:
( � I ] New System [ ] Existing System ( I olding Tank [4] Temporary /Experimental
( ] Repair (Abandonment [ ` Other(Specify)
APPLICANT: 1
PROPERTY STREET ADDRESS: / �e /00
LOT: 4/,
PROPERTY ID #:
SYSTEM DESIGN AND SPECIFICATIONS
T [ st)
A '[ )
D
R
A
I
N
F
I
E
L
D
Oec.�] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
( ] SQUARE FEET SYSTEM
0
T SUr:MIT t3ENC y1 =�I'. fi�;.OR ;r��ilk; CTIOR!
H
E
R BOTTOM OF DRAINFL . LD ELEV ATION
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
THLS SERIV.I. ;LS N. FOR /ue.+01i1QN• S)
4
OH 4016, 10196 (Replaces MRS-14 Form 4016 (page 1) which may be used)
(Stock Number: 5744 -001 - 4016 -0)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION PERMIT
Authority: Chapter 381, FS i.Chapter•10D -6,
BLOCK:
f14 SUBDIVISION:
AGENT:
1 4 Ico Pei< RC)OT
TITLE:
TITLE:
FAC
PERMIT 1
DATE PAID
FEE PAID $
RECEIPT #
[ SECTION /TOWNSHIP /RANGE /PARCEL..NUMBER]
"• (OR TAX. ID' 'NUMBER] • • • , -= •
qi
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 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.
•
GALLONS / GPD) EPTIC TAN/AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:( )
[GALLONS / GPD] CAPACITY _ 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 MRS NO. OF PUMPS: [ ]
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND ( ]
CONFIGURATION: [ ] y T�RENCH. [ G- ]-BED' [ ,] •
LOCATION OF BENCHMARK :9 ' / . (�
ELEVATION OF PROPOSED SYSTEM SITE [/C)"] [INCHES /FT] [ABOVE /BELOW] BENCHMARK/REFERENCE-POI
BOTTOM OF DRAINFIELD TO BE [ 4 3. 2- ] (INCHE yFT) [ABOVIIIENCHMARIC /FERENCE POINT
FILL REQQU�IRED: ] INCHES EXCAVATION REQUIRED: C:3 INCHES
R S`�ALL 1 OF - I LOAM COARSE SAN D
UNDER DOTE C'vz OF DRAINFIELD
2:7_ . _(L,4CHD
EXPIRATION DATE: // :2 �?f-
— 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: Minimum specifications from Chapter 10D-6, FAC.
DRAINFIELD: Minimum specifications from Chapter 10D -6, FAC.
OTHER: Other specifications, such as operating permit requirements, low- volume flush toilets, variance provisos.
SPECIFICATIONS BY: Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY: County Health Department personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by County Health Department.
EXPIRATION DATE: One year from date issued if the system has not been installed. Permits for system repairs become void 90 days from the
date issued.
APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
Authority: Chapter 381, FS & Chapter 10D -6, FAC
AA n q ' AGENT: 4 p,„:„4 5 ) / & V 4
PROPERTY STREET ADDRESS: /3 q /,e70 c
LOT: BLOCK:
PROPERTY ID #:
[
[
[
a/4-
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
TANK INSTALLATION
[01] TANK SIZE [1],F: [2] n
[02) TANK MATERIAL ar't al.e4C
[03] OUTLET DEVICE
[04] MULTI- CHAMBERS
(05) LEGEND
[06] WATERTIGHT
[07] LEVEL
[08) DEPTH OF LID
DRAINFIELD INSTALLATION
[09] AREA [10E.;/: /2
[10] DISTRIBUTION BOX
[11] NUMBER OF DRAINLINES
[12] DRAINLINE SEPARATION 3 �o
[13] DRAINLINE SLOPE �.
�
[14] DEPTH OF COVER /S J
[15] SYSTEM ELEVATION
[16] SYSTEM LOCATION
[17] DOSING PUMPS
[18] AGGREGATE SIZE 44
[19] AGGREGATE SOURCE
[20] AGGREGATE WASHED
[21] AGGREGATE DEPTH
FILL /EXCAVATION MATERIAL
( 22] FILL AMOUNT )P
] [23] FILL TEXTURE
] [24] EXCAVATION DEPTH
] [25] EXCAVATION AREA
] [26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS:
[
[
[
CONSTRUCTION
': Form 4016, Mar 92 (Obsoletes previous
Number: 5744 - 002 - 4016-4)
FINAL SYSTEM [APPROV ! /DISAPPROVED]:
4
SUBDIVISION:
DISAPPROVED]: d
SQFT
editions which may
[SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
[
[
SETBACKS
[27) SURFACE WATER
[28] DITCHES
[29] PRIVATE WELLS
[30] PUBLIC WELLS] -
[31] IRRIGATION WELLS
[32] POTABLE WATER LINES 3
[33] BUILDING FOUNDATION&
[34] PROPERTY LINES / O r'
[35] OTHER
FILLED /MOUND SYST
[36] DRAI D COVER
3 :OULDERS
[ [38] SLOPES
[39] STABILIZATION MATERIAL
DITIONAL INFORMATION
[ [40] UNOBSTRUCTED AREA
[ ,] [41] STORMWATER RUNOFF
[42]
[43]
[44]
[45]
[46]
[47)
[48]
ALARMS
MAINTENANCE AGREEMENT
BUILDING AREA
PLUMBING FIXTURES
CINTL CIOR G DIN ,9 6e ' _�
CONTR ACTOR yy / /dd
OTHER
ABANDONMENT
�
[ y [49] TANK PUMPED g /a° fer
[ 1] [50] TANK CRUSHED AND FILLED _
ill/ Z-4-n/ J q
not be used)
PERMIT # ,2
RECEIPT # 235
FEE PAID $ O O
DATE PAID ZS'd % %
/ /
CPHU DATE:
CPHU DATE: (�
Page 2 of 2
INSTRUCTIONS:
PERROT NUMBER: Permit tracking number assigned by CPHU.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized reprecentative.
MAILING ADDRESS: P.O. box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#: 27 character number for property. (property appraiser ID # or cection/township /range /parcel number)
COUNTY PUBLIC HEALTH UNIT CHECKS [X] ITEMS NOT IN COMPLIANCE WITH CONSTRUCTION PERMIT AND CHAPTER 10D -6 FAC.
INFORMATION IS COMPLETED BY CPHU ON FOLLOWING tTEIVIS:
TANK SIZE (gallons)
TANK MATERIAL (concrete, fiberglass, etc)
LEGEND (manufacturer code)
DRAINFIELD AREA (square feet)
SYSTEM ELEVATION (actual or in relation to reference point)
DOSING PUMPS (number installed)
SETBACKS OTHER (as required)
STABILIZATION MATERIAL (date mound stabilized)
CONTRACTOR (contractor installing system)
ADDITIONAL INFORMATION OTHER (as required)
ABANDONMENT TANK PUMPED (date)
TANK CRUSHED AND FILLED (date)
EXPLANATION OF VIOLATIONS
VIOLATIONS:
CONSTRUCTION APPROVAL:
FINAL APPROVAL:
AS BUILT INSTALLATION SKETCH
Record item code number, explanation of violation, and required corrective action.
Circle approved or disapproved. CPHU signature and date of inspection.
Circle approved or disapproved. Final approval shall not be granted unit the CPHU has confirmed that building
construction and lot grading are in substantial compliance with plans and specifications submitted with the permit
application. CPHU signature and date of approval. .
ELEVATION WORKSHEET ELEVATION OF BENCHMARK OR REFERENCE POINT:
(+1 SHOT
I.I.
ELEVATION
EXISTING GROUND
H.I.
[ -] SHOT
TOP OF AGGREGATE
H.I.
[ -] SHOT
H.I.
1-1 SHOT
• p
N
O