514 NE 101 St (10)PERMIT APPLICATION FOR MIAMI SHORES VILLAGE
Date . 't490 Job Address V /N /VL /o ,'s rs r Tax Folio
Legal Description Historically Designated: Yes No
4A/Mat) iG J /V )2 - - R ,/ Master Permit # 7 2 €�
Phone q3 1I
G.L o -tio �'� Tic Address u1
A) . l / /%y e Mitml /a/
. QGPhone l �5/ — 7676
Owner/Lessee essee / Tenant L
Owner's Address ,5l L/ NLE /0/457" o /-
Contractin Co.
Qualifier TARE'-A l) F FUF Q
State # Municipal # Competency # Ins. Co.
Architect/Engineer Address
Bonding Company Address
Mortgagor Address
Permit Type (circle one): BUILDING ELECTRICAL LUMB G MECHANICAL ROOFING PAVING FENCE SIGN
WORK DESCRIPTION I J1e
Square Ft. 8 0
Estimated Cost (value) 4 /7 00. 00
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 constructio • : • zoning. Furthermore, I authorize the above -named contractor to do the work stated.
or Condo President
4 -4», - c.
Signature of owner an
Notary as t
My Commission Expires:
LESTER E. CROCKETT
My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
I 1 Personally Known 1 1 Other I.D
FEES: PERMIT 3S-" RADON
APPROVED:
D
Date
Notary as to Contr
My Commission Expires:
C.C.F. l� Z �NOTARY
A
`► 2 'OOA C — R'S
uilder Date
j 49:1/
Date
LESTER E. CROCKETT
My Comm Exp. 5/20/2001
Bonded By Service Ins
No. CC649326
1 1 Personally Known 1 1 Other I.D
BOND ?OD
2b
TOTAL DUET 3 �-
zonting Biding / Electrical
Mechanical Plumbing f 1 ' j Engineering
Scale: Each block represents 5 feet and 1 inch = 50 feet.
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Notes:
S'ItFP\1•\cV- - 5' tA G K
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SI , NATURE r��
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CM►,rr - Q-P TJ (L,
TITLE
Date 02
Site Plan submitte
Plan Approved
By
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number 96 12 -'O L t ( )
PART II - SITE PLAN
Not Approved
p .. \ /CJ 't s «) % k)
I
Ag' O
ALL CHANGES MUST BE APPROVED BY THE COUNTY PUBLIC HEALTH UNIT
I-IRS-H Form 4015, Feb 85 (Obsoletes previous editions which may not be used)
(Stock Number. 5744- 002- 4015-6)
County Public Unit
Page 2 of 3
APPLICANT: STE F�N)G1L
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
Authority: Chapter 381, FS & Chapter 10D -6, FAC
AGENT: LL-Oy O - Ni012TN DADE (SEPTIC
MAILING ADDRESS: B _ r („ L s, T g et ._ 7) t t AT.4 1 33) 62
PROPERTY ID #:
PROPERTY STREET ADDRESS: 5)9r _ ( (01 & may SET
DIRECTIONS TO PROPERTY:
1
2
3
4
Alt
SF R -0
- .3 ae 0 x0 n S
[ NJ Garbage Grinc)ers /Disposals
[ 1s j Ultra -low 'Volute Flush Toilets
APPLICANT'S SIGNATURE:
PERMIT # _
DATE PAID 2 -14 -Qk
FEE PAID $ 5).00
RECEIPT # -2.301:0
O
•
TELEPHONE: +p ( 44 /'
APPLICATION FOR:
[J ] New System [N] Existing System [N] Holding Tank [NI] Temporary /Experimental
] Repair [N] Abandonment [N] Other(Specify)
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. ATTACH BUILDING PLAN AND TO -SCALE
SITE PLAN SHOWING PERTINENT FEATURES REQUIRED BY CHAPTER 10D -6, FLORIDA ADMINISTRATIVE CODE.
.PROPERTY INFORMATION [IF LOT IS NOT IN A RECORDED SUBDIVISION, ATTACH LEGAL DESCRIPTION OR DEED]
LOT: N p. BLOCK: SUBDIVISION: f4) DATE OF
eEtze-
po
SUBDIVISION. ) C 1 -72-
[Section /Township /Range /Parcel No.] ZONING: _/
PROPERTY SIZE:, ., ACRES [Sgft /43560] PROPERTY WATER SUPPLY: [ ] PRIVATE [1(] PUBLIC
BUILDING INFORMATION [y] RESIDENTIAL [N] COMMERCIAL
Unit Type of j No. of Building # Persons Business Activity
No Establishment Bedrooms Area Sgft . Served For Commercial Only
N ] Spat/Hot Tubs 1 ] Floor /Equipment Drains
] Other (Specify)
DATE: 6) I
HRS -H Form 4015, Mar 92 (Obsolete previous editions which may not be used) Page 1 of 3
(Stock Number: 5744 - 001-4015-1) •
INSTRUCTIONS:
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, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK,
SUBDIVISION:
PROPERTY ID#: 27 character number for property. (CPHU may require property appraiser ID # or section/township• range /parcel number.
PROPERTY SIZE:
WATER SUPPLY: Check private or public
PROPERTY ADDRESS: Street address for property. For lots without an assigned street address, indicate street or road and locale in county.
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION: Check residential or commercial.
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 1OD-6, FAC. Examples: single family, single wide mobile home, restaurant,
doctor's office.
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinely provide sleeping accommodations for
occupants.
# PERSONS: Number of persons residing, using, or working in establishment. For residential establishment, 2 persons per bedroom are
assumed.
BUSINESS ACTIVITY: For commercial applications only. List number of employees, shifts, and hours c f operation, or other information required by
Table 11, Chapter IOD -6, FAC.
FIXTURES: Mark each listed fixture with number installed or "NA" if not applicable.
SIGNATURE: Signature of applicant or agent. Date application one day submitted to the CPHU w ith apr roFriate fees and attachments.
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.
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.
DATE OF SUBDIVISION: Official date of subdivision recorded in county plat books (month /day /year) or date lot originally recorded. Dividing an approved
lot into two or more parcels for the purpose of conveying ownership shall be considered a subdivision of the lot.
Net usable area of property in acres (square footage divided by 43,560 aquare feet) exclusive of all paved areas and prepared road
beds within public rights -of way or easementa and exclusive of streams, lakes, normally wet drainage ditches, marshes. or other
such bodies of water. Contiguous unpaved and noncompacted road rights -of -way and easements with no subsurface obstructions
may be included in calculating lot area.
BUILDING AREA: _ Total square footage of enclosed habitable area of dwelling unit, excluding garage. :arr.-rt. exterior storage shed, or open or fully
screened patios or decks. Based on outside measurements for each story of struzwie .
ATTACHMENTS. A site plan :.ray.n to scale, showing bo,ndar.es » _. dimen_: . e • r,
:. .. . , nsite sewage disposal e cf pr Fen y, a : i t '� or prcpc se i w ells. 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.
LOT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
S T F F J Cg
ki Pc BLOCK: NA
PROPERTY SIZE CONFORMS TO SITE PLAN: [ ]
TOTAL ESTIMATED SEWAGE FLOW:
AUTHORIZED SEWAGE FLOW:
UNOBSTRUCTED AREA AVAILABLE:
THE MINIMUM SETBACK WHICH
SURFACE WATER: 100 FT
WELLS: PUBLIC: (00 FT
BUILDING FOUNDATIONS:
USDA SOIL SERIES:
BENCHMARK /REFERENCE POINT LOCATION:
SITE EVALUATED Y:
HRS-H Form 4015, Mar • 1.:.letes previ
(Stock Number: 5744 - 003 - 4015 -1)
SUBDIVISION:
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES
10 YEAR FLOOD ELEVATION FOR SITE:\... 25.5
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture Depth
r✓ tA1.1 Pow 01 Qf t to _1
to
to
to
to
to
to
to
to
OBSERVED WATER TABLE: - PA' INCHES [ABOVE /
ESTIMATED WET SEASON WATER TABLE ELEVATION:
HIGH WATER TABLE VEGETATION: [ ] YES [ ] NO
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ ] TRENCH ()
REMARKS /ADDITIONAL CRITERIA:
f\J )4
ELEVATION OF PROPOSED SYSTEM SITE IS . 10 [ k3Q'C!#S /FT] [ABOVE ..c ] BENCHMARK/
CAN BE MAINTAINED FROM THE
DITCHES /SWALES:
LIMITED USE: OA FT
5 FT PROPERTY LINES:
ition which may not be used)
( ` y S
SOIL PROFILE INFORMATION SITE 2
BED [ ] OTHER (SPECIFY)
PERMIT # /
AGENT: f (',of) _ I D&t
PROPERTY ID #: [Section /Township /Range /Parcel No. or Tax ID Number]
5 ? Y- f t__lD 1 StJ 3 138'
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.
YES [O NO NET USABLE AREA AVAILABLE: , 72 ACRES
v GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
0 GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
SQFT UNOBSTRUCTED AREA REQUIRED: 6o SQFT
PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
1 FT NORMALLY WET? [ ] YES 0 NO
PRIVATE: N _ FT NON- POTABLE: /J1 FT
S FT POTABLE WATER LINES: 1 s � FT
10 YEAR FLOODING? [ ] YES 00 NO
NGVD SITE ELEVATION: 11,71. FT '3 /NGVD
Munsell # /Color Texture Depth
Sf uWfl c<',4rJ►I o ff t672.."
to
to
to
USDA SOIL SERIES: (S4tIO y
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EXISTING GRADE. TYPE: [PERCHED / NT]
11
1•Z SINCHES [ ABOVE / any ] EXISTING GRADE.
MOTTLING: [ ] YES [-4 NO DEPTH: N A INCHES
DEPTH OF EXCAVATION:
DATE :°
E POINT
INCHES
Page 3 of 3
INSTRUCTIONS:
PERMIT /1: Permit tracking number assigned by CPHU.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
PROPERTY 1D#: 27 character number for property. (property appraiser ID /1 or aection/township /range /parcel number)
PROPERTY SIZE: Check if property size 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 end 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 1 (residences) 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 1OD -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 of the 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 non applicable 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 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 documentation submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE I SITE 2 SITE 3
[ +] SHOT: H.I. H.I. H.I.
H.1. [ -] SHOT [ -] SHOT [ -] SHOT
CONSTRUCTION PERMIT F9R:
[V] New System ( I Existing System [/YS olding Tank [ k Temporary /Experimental
[Y] Repair, [II] Abandonment ( ,t Other(Specify)
APPLICANT: S NI
AGENT: L /U � u l ., 44t - A 4 . I D C" S_ P [. •
PROPERTY STREET ADDRESS: n ) y '°.. 1 C) I s - 1 - Re //
LOT: N BLOCK: /V ,/� SUBDIVISION: AV
PROPERTY ID #: N2 [SECTION /TOWNSHIP /RANGE /PARCEL NUMBER]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 1OD -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 DESIG ,- FIgl
T [ rZAID ]
A [
N [
0
T
H
E
R
STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES DATE PAID
ONSITE SEWAGE DISPOSAL SYSTEM FEE PAID
CONSTRUCTION PERMIT RECEIPT #
Authority: Chapter 381, FS & Chapter 1OD -6, FAC
GPD] TIC TAN' /AEROBIC UNIT CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] [GALLONS / GPD] CAPACITY MULTI- CHAMBERED /IN SERIES:[ ]
] 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: [ ]
1 D [
I R [ ] SQU ARE'. h`�T
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ 4:9] f T] [ABOV
E BOTTOM OF DRAINFIELD TO BE [ 36' ] INCH "S /FT] [ABOV
L �'.�
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [.SC)] INCHES
^7
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED: oz, /6,...y7 fy
RIMARY DRAINFIELD SYSTEM
SYSTEM
[. [ ] FILLED [ ] MOUND [
[ ] TRENCH [ 44-"BED
•
q 2 _
TITLE:
TITLE:
HRS -H Form 4016, Mar 92 (Obsoletes previous editions which may not be used) •
(Stock Number: 5744 - 001 - 4016 -0)
APPLICANT
BENCHMARK/
•
�0�
2 -/
$
23, fp
BENCHMARKAiiFERENCE POINT
CPHU
EXPIRATION DATE: 66(4'1f
Page 1 of 2
S:
NU!a'' k: Permit tracking numker assigned by CPaaJ.
APPL:CA'!" C! =O'?: Check type of permit, if 'Cther' specify type in Waal:.
A`_'PL CA1\!7: Property owner's full name.
TEL'E. Telephone number for applicant or agent.
ACEN L : Property owner's legally authorized representative.
MA_L N 3 ADDRESS: P.O. box or street mailing address for applicant or agent.
SYSTEM/ DESIGN AND
SPEC; !CATIONS:
LOT, 3LCCX, SUBDIVISION or
PROP= ',.• IDtI: 27 character id number for property. (CPHU may require property appraiser ID I1 or cection /township /range /parcel number)
s
AN �: Minimum specifications from Chapter 10D-6, FAC.
DRA. :NPIELD: Minimum specifications from Chapter 10D-6, PAC.
OT EER: Other specifications, such as operating permit requirements, low - volume flush toilets, variance provisos.
SP CiFICATIONS 3Y: Name of individual providing specifications. Lf designed by a registered engineer must be seder'.
APPROVED BY: County Public Health Unit (CPHU) personnel reviewing and approving permit.
DATE ISSUED: Date permit is issued by CPHU.
:De 9 P.AT ION DATE: One year from date issued if the system has not been installed. Permits for system repairs hecome void 90 days from the date
issued.
Alh