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PL-15-1821 Miami Shores Village �, JUL 2.1.2095 Building Department BY: 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(30S)762-4949 FSC i®�y BUILDING Master Permit No PERMIT APPLICATION Sub Permit No,�//� f 2) ❑BU ING [--jELECTRICROOFING E] REVISION F1 EXTENSION [:]RENEWAL VE PLUMBING M MECHANICAL MPUBLICWORKS M CHANGE OF E] CANCELLATION [:] SHOP CONTRACTOR DRAWINGS JOB ADDRESS: lel 1 10-1 S t City Miami Shores County Miami Dade Zip: 33\l0� Folio/Parcel#: t ` Z1-5(0 - Q 19!7 • Q7 jg Q Is the Building Historically Designated:Yes NO �✓ Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder): UII 11Ct 6t Mc fcd&io Phone#: Address: S:t City: State: Zip:tel L� Tenant/Lessee Name: b.1 i Phone#: Email: CONTRACTOR:Company Name: 2K&4Cgj 2c5 1 Phone#: --5qg;L*-:)a(0CD Address: S©H°J ) '�U St, City: o 1 State: fes[ Zip: �c�Lt� Qualifier Name: k/'�x t ie'- Phone#: State Certification or Registration#: 0--PG 1 SIS 6,R K2=1 Certificate of Competency#: DESIGNER:Architect/Engineer: I1ko'i---IS Phone#: 3D 5"S o5-c371L.{!E� Address: 1 3L4L4 1 SL S TPjry- City: 'I cziL�,► State: r-L' Zip: Value of Work for this Permit:$ Q ,0C)o Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition Description of Work: 1 Specify color of color thru tile: ,^ Submittal Fee$ 4r aJv Permit Fee$ ' CCF$ CA/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary$ Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ TOTAL FEE NOW DUEel $ (Revised02/24/2014) Bonding Company's Name(if applicable) I Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) _ Isi ! (� Mortgage Lender's Address 3 1 A City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS, ETC..... 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. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT 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." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law b,ochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of comme'7cement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued in the absence of such posted notice, the inspection will not be approved and a reinspection fee will be charged. P Signature Signature OWNER or AGENT CC:NTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this _ day of t1 Q 20 i5 ,by `0 day of 20 1 f� by 4�i� t i ��� p ersona I known ;s fi1,� 11c�areiG1 who is ersonally know o me or who has produced as me or who has produced_ as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: +(CIL Print: L� 1 �-} �,ea i� _�,®.- Print: 4 Seal: oo Luz Heletl2 i o���� YPpBso uZHelertlAsh°irl Seal. ��o�?�,YP� s�COMialSSICR¥FF019053 ?_�' �COtdi:il.SSICN FF01905� 'x' a" FdAY 19.2017 =� "E(PIRES: ,- EYPIRES: MAY 19,2017 �'�;;F'oF °'�%Wffi.&NRONNOTARXCQM ***s**s***s******�iy�L's*>�aKS?���1TA���I�***************e**s*******s*ssr�*a.*ss$*******s****s***ss***ss*s***sa* APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) r 0 EP .4P MAP OF SURVEY Scale: i°=20' ._. _.- -.- --- -- _.— —. _ —T ..- — T 0'Asphalt t. 1��1..,-.. Found 1/2' - r -- - I Iron Pipe `� Chaln Unk Fen c; No Id. �� 4'high 1.7' Found 1/2' J Pe NORTH' ` Ask& F?0Jd No Id. } 1a• � I o.os i a to r13 00o z N. z Oft 11.33' O 17.00' W; w-r A/C Sev. $ 11.43' 13 l: ui O 16.65'_ b v; 21�m o 4 MN W 16.85' re a Tarra4ro. o g x d o •3n 10.00' N $ 31.50' •« o ' � �n 1-STORY-BUILDING .N Residence No.5 10.70F.F.Efev,12.60 Ff. 9.9 a orch +tri 14.05' 1 t4.6a 10_la 40' J z - - a. sAo 80'TOTAL R/W A 3 oe� , Found 1/2' i LOLL cod N( 4 e 1 { Iron No Idlpe� ' 1Q,3Q g�� •; Found 1/2' Iron Pipe 91 4,0 No Id. "j 51d ci14u • N89°Sa'45"W • 5.00', 4 1 A�.f w • .� 4 ♦ 3 10.30 1O Q • •:. ; 20Pprkviax • r~ •. 17.30' • ;:.I' .. •�1`. blc�-Ftc ✓erq�r3t ��� • &_ i 'i -6,601, �y. • • • ' a LOCATION MAP Scale: 1'= 100' 7.5'Alley — 7.51A;75' 75' j 75° `Y NORTH Block -211 - Lu 41 13 14 15 16, 40' < 75' 75' 71T ,r ✓75' LEGAL DESCRTMN: FOLIO:11-2136.007-0480 LOT 16,BLOCK 211," DUNNING'S MIAMI SHORES EXTENSION No. 3 ACCORDING TO THE PLAT THEREOF,AS RECORDED IN PLAT BOOK 42,AT PAGE 33,OF THE PUBLIC RECORDS,OF MIAMI-DADE COUNTY,FLORIDA. PROPERTY ADDRESS: CERTIFIED TO: 5 N.W.107th STREET,MIAMI SHORES,FLORIDA 33168 MILLICENT F.McFADDEN FLOOD ZONE: 'X' COMMUNITY:120652 PANEL 0302 MADELINE COLLINS DATE OF FIRM:09-11-2009 SUFFIX:L ELEVATION:N/A GENERAL NMS: 1)LEGAL DESCRIPTION PROVIDED BY OTHERS. 2)EXAMINATION OF THE ABSTRACT OF THE TITLE WILL HAVE TO BE MADE TO DETERMINE ABBREVIATIONS AND LEGEND: RECORDED INSTRUMENTS,IF ANY,AFFECT THIS PROPERTY. 3)THE LANDS SHOWN HEREON WERE NOT ABSTRACTED FOR EASEMENT OR OTHER A/C =DENOTES AIR CONDITIONING UNIT RECORDED ENCUMBRANCES NOT SHOWN ON THE PLAT. CONC. =DENOTES CONCRETE 4)UNDERGROUND PORTION OF FOOTING,FOUNDATIONS OR OTHER IMPROVEMENTS (M) -DENOTES MEASURE WERE NOT LOCATED. (R) -DENOTES RECORD 5)ONLY VISIBLE ON ABOVE GROUND ENCROACHMENTS LOCATED. (C) =DENOTES CALCULATED 6)WALL TIES ARE THE FACE OF THE WALL R/W -DENOTES RIGHT-OF-WAY 7)FENCE OWNERSHIP NOT DETERMINED. (Z -DENOTES CENTERUNE 8)BEARINGS REFERENCED TO UNE NOTED AS B.R. U.E. =DENOTES UTILITY EASEMENT 9)BOUNDARY SURVEY MEANS A DRAWING AND/OR GRAPHIC REPRESENTATION OF P.B, =DENOTES PLAT BOOK THE SURVEY WORK PERFORMED IN THE FIELD,COULD BE DRAWN AT A SHOWN SCALE PG. -DENOTES PAGE AND/OR NOT TO SCALE. ® -DENOTES WATER METER 10)NO IDENTIFICATION FOUND ON PROPERTY CORNERS UNLESS NOTED. CID-) -DENOTES WOOD POWER POLE 11)NOT VALID UNLESS SEALED WITH THE SIGNINGS SURVEYORS EMBOSSED SEAL -o---- =DENOTES WOOD FENCE 12)DIMENSIONS SHOWN ARE PLAT AND MEASURED UNLESS OTHERWISE SHOWN. =DENOTES CHAIN LINK FENCE 13)ELEVATIONS IF SHOWN ARE BASED UPON N.G.V.D.1929 UNLESS OTHERWISE NOTED. 0 -DENOTES IRON FENCE 14)THIS IS A BOUNDARY SURVEY UNLESS OTHERWISE NOTED. —OH— =DENOTES OVERHEAD WIRES 15)THIS BOUNDARY SURVEY HAS BEEN PREPARE FOR THE EXCLUSIVE USE OF THE ENTITIES (9) =DENOTES FOUND IRON PIPE(NO ID.) NAME HEREON.THE CERTIFICATIONS DO NOT EXTEND TO ANY UNNAMED PARTIES. A =DENOTES FOUND NAIL AND DISC 16)BENCHMARK:N-M7.................ELEVATION: 10.54 FEET LOCATION:N.E.104th STREET&N.MIAMI AVENUE CERTIFICATION: ; a a : • SURVEYO�t'�cmrr,,_tFiCAT1�:IIE m: mFYT�TiQ6aduWDARY SURVEY"IS A TRUE AND CtdF>#L7GT fi All OFAP7051FLORIDA PREPARED ALL BEARINGS AND DISTANCES SHOWN HEREON ARE UNDER MY DIRECTION.THIS COMPLIES W[TH THE TICAL STANDARDS, AS FORTH BY THE SPATE OF FL ABORECORD AND MEASURE UNLESS OTHERWISE NOTED. PROFESSIONAL SUR _ t71L4AND MAPPEWN : ADnIBVL�rRrl[✓vec �MIRS 'x15 FLORWA STdkTUrES. MIGUEL ESPINOSA LAND SURVEYING INC. r• PROFESSIONAL SURVEYOR AND MAPPER • ' r ^ed 10666 S.W.190th STREET,SUITE 3111,MIAMI,FLORIDA 33157 SIGN vr ' �(�It�lHESIRM PHONE:(305)262-2992 FAX:(305)964.9303 L B.No.6463 MI OSA / PS.A N .5 )-SPATS OF FLORIDA NOT VALU,y�RHOUT AUTHENTIC EL TRONIC SI AND AUTHENTICATED BOUNDARY SURVEY ELECTRONIC SEAL /OR TH1t161AP NOT 1 LIB► wTiNE SIGNATURE AND THE ORIGINAL RA SEAL OF aUCE SE SURQEY QIND tPPE•R. 0 Original Date: Field date: Revision Date: Drawn by: Job No. • 00• • • • • • • . • 05/21/2015 05/21/2015 05/21/2015 R.U. S-11610 •••: • 0 MOUNTING THE SENSORS Make sure that the arrows of each sensor are pointed towards WARN I N G I each other.Using either the double-sided tape or the screws provided,mount the sensors so that they are less than V,inch away from each other.Sensors must be mounted flush in THE SAFE POOL ALARM IS EXTREMELY LOUD WHEN height and depth,so with some doors or windows,special ACTIVATED.FOR YOUR SAFETY,NEVER PLACE THE Safe Poo I TM custom fitfing may be necessary.Please make sure that the UNIT CLOSE TO YOUR EARS.TO TEST THE ALARM,wired /� non-moving of the magnetic sensor is mounted on portion the mounting surface and the AWAY BEFORALWAYS USE E TESTING/CTPROTECTION VATING DIRECT THE ALARM.UNI'l Model I S 187 D standalone sensor is mounted on the door/gate.(See Fig. Area Entry Alarm 5/Fig.6) IT IS PROHIBITED BY LAW TO REMOVE THE INSTALLED r 1� MOUNTING OUTDOORS ON WOODEN GATES ALARM AFTER IT HAS PASSED INSPECTION t Using the provided mounting !^� template printed in this Important Warranty Information: a manual,"e*the limon of rwoaceN r000es A dated proof of purchase Is required for warranty service N the screw holes on the oArE$ F 1 p dewed mounting surface. Drill the screws onto the � ' Customer Service mounting surfacewith .q� 1-888-8TECHKO(1-888-883-2456) J approximately 1/8 inch of ({ ( Website:www.techkomaid.com �\ Ovead remaining.Slide the / unit over the screws and \� secure the unit by pushing Fig.5 Mfg.By ?ECIM' i''� i, d downward as snows in Fig.5.You may need to adjust the screws ,• /y9 towards or away from the mounting surface to provide a more secure 9767 Research Drive, r o...., W hl Make sure that the arrows of each sensor are pointed in the same Irvine,CA 926184626 direction.Note:Wooden gates do not require Ore sensor housings ° ° ,i MADE IN CHINA f►JI MOUNTING the OUTDOp fies, METAL GATES fl,((" I� w using the provided zip flea. wouwrcw our°oowa , VV ' d mattach the alarm body to Ore °wwew wrea c , �metal gate frame.ISee Fig.B) Using a small flat head _Up 9700127scrUy the recessed sensor spgently pry acer '4 - COMPL201 WITH UL 2017 of Ore sensor housing.(FIg.6y _ Make sure that the arrows of �- ' each sensor are pointed in Ore same direction as Ore sensor Fig s I USA Patent:No.5,473,310 F 1 � housing before placing are magnetic sensors inside the sensor `t housing.Note:Metal gates may interfere with the magnetic sensor No.6,727,819 function.Use spacers provided to ensure sensors operate properly NOTICE Secure the sensors using the zip ties onto the gate frame.Make 'r sure that the sensors'arrows are pointed towards each other and y ;z that the sensors are less than%inch apart. THIS PRODUCT IS PROTECTED UNDER FEDERAL j PATENT,TRADEMARK AND COPYRIGHT LAWS AND _MAINTENANCE I LAS PREVENTING UNFAIR COMPETITION.NO c DUPLICATIONON TIOR SIMULATION OF THIS PRODUCT --- —--- -- "� IS PERMITTED EXCEPT BY WRITTEN AUTHORIZATION I •••• _ When the alarm volume becomes low,or the unit does not OF TECHKO,INC. • • produce normal alarm sound,the red light will illuminate, o kRAXIM you must replace the 9-volt battery. TECHKO AND THE CONFIGURATION OF THIS PRODUCT t � i ARE TRADEMARKS OF TECHKO INC. •. �.t d + ce y The Safe Pool's plastic parts resists ultraviolet rays from COPYRIGHT 1994 TECHKO,INC. 909606 • M l+••fa direct sunlight exposure.However,slight discoloration ALL RIGHTS RESERVED 000:0* over time is normal. MADE IN CHINA -. ..-- -- •• • •tea• - •••• • •• ••••• 00.00• • • 0000• • • 0000•• •• •• • • 0000•• • 0 fee • 0000•• • • • • • 0000•• 0000•• • • • 0000•• • • • r - - "- Keep this manual for future reference. MOUNTING: INTRODUCTION WARNING:The alarm should be positioned close to The Safe Pool can provide valuable protection when ngratulations on your purchase of the TECHKO Safe used correctly.However,it cannot guarantee complete the door high enough to be out of the reach of children. TEMPLATE of model S187D safety alarm.The Safe Pool can bePProtection against accidents or injuries.Therefore, As each mounting application varies,Techko suggests ed to provide a high volume alarm alert when children Techko cannot be held responsible for any loss,damage, testing the units installation location and effectiveness MODEL S187D ve entered a pool or spa area.The S187D can be used or injury that may occur. before permanently mounting the S187D. tdoors on wood or metal gates,or indoors on doors and I -- -AL - ON -- - - MOUNTING INDOORS idow leading directly to potentially dangerous areas. [ INSTALLATION ] Using the provided mounting template printed in this OPERATION WARNING:Read all Installation and operation manual,mark the position of the screw holes on the --- --- - - - -- _ - —- - instructions thoroughly before proceeding with desired mounting surface. r e Safe Pool is designed to sound a loud alert when installation.Note:Not all parts Included are needed for - ciissouw Y" idren enter through a Safe Pool protected door/gate. installation.Please read the different mounting *The Additiona swy SCREW HOLE ien properly installed,the Safe Pool will allow adults to instructions to see what is needed for your specific delay button may ss through the protected doorigate and immediately shut application. be mounted on the - the sounding alarm other side of the i INSTALLING THE BATTERY: ien powered,the Safe Pool is always in protection mode. 1.When testing,before installing the battery,use a rubber entrance.it vWh n \1 e alarm will activate the instant when the doodgate opens band to temporarily secure the two magnetic sensors p / more than 1/2 inch(when the magnetic sensors are apart together with the arrows pointing toward each other to delay the alarm / ore fe 8-12 more than 1/2 inch).Once the alarm activates,it Will sound avoid setting off the alarm unintentionally.During the bo seconds la before alarm is ntinuously until the BYPASS button is pressed. actual installation of the alarm,it's best to install the f� t{ battery after it's mounted to avoid the alarm going off triggered,allowing I t yen passing through the door/gate press the BYPASS time to secure the t Pa 9 � 9 Pr unintentionally. door/ ate tion,then open the doodgate,pass through Fig.a and close 2.Remove the battery cover of the unit and install a new 9 g . r doorigate Within 8-12 seconds and thea arm Will not Volt battery.Replace cover.(See Fig.2) Gvate.____ 3.if you are sensitive to loud sound,please wear ear *The Additional magnetic sensors allow the unit to be -FEATURES , protection against the loud alarm siren before testing used on sliding door with screens. --- -- the alarm. Alarm will sound on when BOTH sets of magnetic 'asy installation for gate,door or window protection 4.Once the battery is connected,the IY a9 Vater/weather resistantsensors are apart,there for allowing the slider to be open unit is now ON and working.To test Volt battery power{rtat induced) while still providing protection at the screen door figh output 110-115 dB alarm siren the alarm siren,make sure you .ow Battery/signal LED Indicator have ear protection before testing. MOUNTING INDOORS USING DOUBLE-SIDED TAPE )ptional additional BYPASS button for delayed entry from After ear protection is in place, rq i Make sure that the mounting surfaces for the double-sided ther side of door or fence separate the magnetic sensors tapes are completely dean. Attach the double-sided tapes )ptional additional magnetic sensor for screen door apart by more than'/inch.The onto the rear of the unit,and then secure the unit onto the At/entry alarm should sound immediately after the sensors are desired mounting surface. separated.Press the BYPASS button and immediately UgT scero u T eq�YPASS secure the two magnet sensors together again to avoid MOUNTING INDOORS USING SCREWS the alarm sounding off unintentionally. Using the provided mounting template printed in this -- ZIP TIE manual,mark the position of the screw holes on the {n LED LIGHT WARNINGS desired mounting surface.Drill the screws in to the 1.When the battery homes low in charge or the volume mounting surface with SCREW HOLE ✓? s Fig.t becomes weak,the LED light will illuminate.The 9 volt approximately 1/8 inch of thread 06696 6CRM battery must be replaced. remaining.Slide the unit over the • • �s.s •••►••' ae 2.Upon battery installation,the unit will beep once and the, screws and secure the unit b �� • • • • LED light will flash 10 times as it prepares to become pushing It downward,as shown in •• • •••• '• - 1 3.ear When a bypass button is pushed,the LED light Fig.4.You may need to adjust the •••••• •• •••••• _IMPORTANT SAFETY TIPS: I illuminates to indicate acknowledgement ro PASS through. ��towards e �y from the 4 •••••• • arm siren is VERY loud;NEVER place the unit close to 4.After the bypass button is pushed in and released,the mound surface to vide a more �• •••• • • ••••; rrs. LED light will flash 10 times to allow ss through and to secure • • • • • slap the unit high enough to be out of reach of children 9 I •••• s •• 0000* 9 g prepare the unit to become armed again. I! • • 4'or higher is recommended. 000000 • • 96069 • • •••••• •• •• • •••••• • s Cyd a e RECRIVE-D U � ' /3 JUL 21 2015 ST .OF FLORIDA PERMIT NO. DE CDATE PAID: ONSITE SENAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #: ,•`°D1 APPLICATION FOR CONSTRUCTION PERMIT APPLICATION FOR: [ ] New System Existing System [ ] Holding Tank [ ] Innovative [ ] Repair [ ] Abandonment [ ] Temporary [ ] APPLICANT: MALLICENT MCFADDEN AGENT: SOUTHERN SEPTIC TELEPHONE: 305 598-8266 MAILING ADDRESS: 1421 SW 153 PATH MIAMI,FL 33194 TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105(3) (m) OR 489.552, FLORIDA STATUTES. IT IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR PLATTED (bWDD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION LOT: 16 BLOCK: 211 SUBDIVISION: DUNNINGSMIAMISHORES PLATTED: 1940 PROPERTY ID #: 11-2136-007-0480 ZONING: RU1 I/M OR EQUIVALENT: [ No ] PROPERTY SIZE: .21 ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [,/ ]<=2000GPD [ ]>2000GPD IS SEWER AVAILABLE AS PER 381.0065, FS? [ No I DISTANCE TO SEWER: N/A FT PROPERTY ADDRESS: 5 NW 107 ST MIAMI SHORES,FL 33168 DIRECTIONS TO PROPERTY: NW 103 ST TO NORTH MIAMI AVE TO 107 ST BUILDING INFORMATION [ ✓] RESIDENTIAL [ I C01=RCIAL Unit Type of No, of Building Commercial/Institutional System Design NO Establishment Bedrooms Area SqE Table 1, Chapter 642-6, PAC 1 SFR 3 1276 2 3 Ole • • • • •• • [ ] Floor/Equi t " a [ ] Other (Specify) 000 0:0 Goo goo 0 0 SIGNATURE: ' V-1D0-L 1 • :6/2SI5 • .• DH 4015, 08/09 (Obs el 415 -r�-OVXus editions which may not be used) Incorporated 64E-6.001, Page 1 of 4 • • • • • • ••• • • • • • • • • • • ••• • • •• •• • • • •• •• ••• • 0 0 000 0 t � . i e Charlie Crist Ana M.V iamonte ttos,M.D.,M.P.H. Governor State Surgeon General DOH# Chapter 64E-6.004(3)(a),F.A.C.: A plan or plat of the lot or total site ownership drawn to scale, showing boundaries with dimensions,locations of any existing or proposed residences or buildings,swimming pools, recorded easements,the on-site sewage treatment and disposal system components and their location on the property,the slope of the property and any existing or proposed wells„potable .and non:potable water litres,including.valves,drain4ge features,filled_areas,unobstructed areas, and surface water bodies. The site plan shall indicate the location of wells,on-site sewage treatment and disposal systems,surface waters and other pertment facilities or features on contiguous or adjacent property. If the features are within 75 feet of the applicant lot,the estimated to the feature must also be shown but need not be drawn to scale. The location of any public drinking water well,as defined in Chapter 64E.-6.002(44)(b),within 200 feet of the applicant's lot shall also be shown,with the distance indicated from the system to the well,and the location of limited use public water system or other public wells,as defined in Chapter 64E- 6.002(44)(b),within 100 feet of the applicant lot must also be shown,or as defined in Chapter 64E-6.002(44)(a),F.A.C.,within 75 feet from a private potable water well(well used only by one or two residences). Chapter 24-12(18),Miami-Dade County Code: The minimum separation between a well or wells and possible sources of contamination shall be a fiinction of the drawdown radius of influence of the well or wells. In no case shall the well be located less than one hundred(100)horizontal feet from any source of contamination. I have read the above and to the best of my knowledge I have provided the Department with full information regarding pertinent facilities and features on all adjacent properties. Furthermore,I understand that any on-site sewage treatment and disposal system permit issued on the basis of said facilities and feature as provided by me and found to be incorrect will be subject to revocation in accordance with the provisions of Chapter 120,Florida Statutes. Property Address: �'^t 1 Date: Signature: Samir Elmi,PhD,PE,DEE,CEHP,Di Environmental Health and Engineering Miami-Dade County Health Department 1725 N.W. 167'Street,Miami,Florida 33056ask •• ••• • • Tel:(305)623-3500 Fax: (305)623-3502 • • • • • •' •• ••i • • • • • • • • ••• ••• ••• • • • • •• • • • •• • • • • • ••• • • • • ••• • • • • • • • • • • • • 060 0• •• • • • •• •• STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number -------------------------- PART II SITEPLAN--------------------------- Scale: Each block re resents 10 feet and 1 inch =40 feet. i 4 x 51 rri ggag g D 92*_10' B 7•_�. M as � w h g 122.78' WAS PP }QQ :n s n QyyNil PI N�Q Y jA 1� X2 �2YY5' `' Z 1 m MIAMI AVENUE Notes: THERE ARE NO PERTINENT FEATURES ON ADJACENT PROPERTIES AND OR ACROSS THE STREET THAT MAY AFFECT THE NEW SYSTEM INSTALLATION Site Plan submitted by: ' ••• •• 2a��/.yid Plan Approved Approved ;Qat S :• •• .. ... .. . . . .. By County Health Department • ... ... ... . . ALL CHANGES MUST BE APPROVED BY THE COUNTY HEA1a'H:DEPA&TMeNT • .. ... . .. . . . . . DH 4015,10196(Replaces HRS-H Form 4016 which may be used) (Stock Number. 5744-002-4015-6) Page 2 of 4 AUTHORIZATION LETTER Department of Health O.S.T.D.S. Corporate Park Office 7769 N.W.48 St Suite 175 Miami, F1 33166 Ref Permit No: Date: lo--L44•1 Address: S tJwJ 1 T? eb � Street number/name City, State Zip Code Property ID: Do 7 And/Or Legal Description: (Property owners full name or legal representative of the property) In representation ot:�t.�'� (My self or property entity full name) As: (. C,,tkrt CN, -,b ,- (Owners or position into entity) Hereby authorize: (Property owners legally authorized agent or company name) To process and obtain the Septic System permit for this property located at the above referenced site• •.. .. . . . •• fee 0:0 fee fee �+ ••• • • Y • ••• • • • • • • • • • • • • ••• • • • ••• • •