PL04-266-267MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 -2204
Buildin ' Inspection Request
Date
Type Insp'n
Permit No. PL- O / - a 6 6 c9 (v7
Name ?AZ
Address S AO .06 q o
Company
Phone # 0 5 (069
Inspection Date
Approved
Correction
Re- Insp'n Fee
/ 7f
Miami Shores Village
'__ r Building Department
N Q ,004 1 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 2001
Permit No.
Master Permit No.
z ay' - b'1
Permit Type (circle): Building Electrical t Mechanical Roofing
Owner's Name (Fee Simple Titleholder) is.) t -- ; ,- rn ( i ri e' <-t�? i Cr-_ - Phone # (' "' 5)1 5 i - 1 ,'. `-k'
Owner's Address (:, 0 N., k:::::. ( f `;fi rC C t
City h\, ;'s , - c , =, V ‘) State F'-- Zip . ,' 1
Tenant/Lessee Name ( Sit rn.0 Phone #
Job Address (where the work is being done) t' G O N G 90 l rc e e
City Miami Shores Village County Miami - Dade Zip c:33 :38
Is Building Historically Designated YES NO '✓"
Contractor's Company Name -4 > re( � Phone # bC ' F E 3
Contractor's Address - M C I O S Sr Zd 1 if 7 b
City t r ra rY• A t State Zip 330 2 3
Qualifier ,rt 5`' Ste)J �
Architect/Engineer's Name (if applicable) N f . Phone #
$ Value of Work For this Permit c00 ° Square Footage Of Work:
Total Fee Now Due $
(Continued on opposite side)
)7 6)-
Type of Work: ❑Addition ['Alteration ew El Repair /Replace ❑ Demolition
Describe Work: R.' ry r- d C L In'v I fs ¥c +-'
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * ** * * * * * **
Submittal Fee $ Permit Fee $ l7-, CCF $ i O f - b CO /CC
Notary $,S,-o Co Training/Education Fee $ i D Technology Fee $ 91
Scanning $ Radon $ Zoning Bond $
Code Enforcement $ Structural Plan Review. $
Bonding Company's Name (if applicable) r
Bonding Company's Address 1
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address J"J
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement 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 a a reinspection fee will be charged.
Signatur
Owner or Agent Contractor
The oregoing instrument was acknowledged before me this . ( The forgoing instrument was ac edged before me this / 0
day of 294' , by A N 0i a P.,-. 6P" = dayo
who is personally o . o me or w • `:: • i 1 ? G
eattuawboti
Sign:
Print:
My Colinission xpires:
Chc 12/15/03
. • .
NOTARY PUBLfC4 , "n
p G Q
JA •5C.1/Xr -
•� -� �
My Co r ns :�ecic�i
y S mnriission JD75t)1)43
(Certificate of Competency Holder)
State Certificate or Registration No. Certificate of Competency No.
Signature
7 ax r -'
who is personally known to me or who has produced
tification and who did take an oath.
NOTARY
Si
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** *********************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED BY`
Engineer
C /
C `/ Plans Examiner
Zoning
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPO
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ X ]New System [ ]Existing System [
[ )Repair [ ]Abandonment
APPLICANT: Frederick, Norma S.
LOT: N/A BLOCK: K
PROPERTY ID #: 11- 3206 - 020 -0010
SYSTEM DESIGN AND SPECIFICATIONS
SPECIFICATIONS BY: Andre, Paul
APPROVED BY: Test II,
DATE ISSUED: Cj' / / d I d`
...._ _. C „n, in,C_f,
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
PROPERTY STREET ADDRESS: 500 NE 90 St Miami Shores FL 33138
]Holding Tank [ ] Innovative Other
] Temporary [ NA ]
AGENT: OWNER,
SUBDIVISION: El Portal Section 4
[Section /Township /Range /Parcel No.]
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E -6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
COMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
MULTI- CHAMBERED /IN SERIES: [Y ]
T [ 900 )Gallons SEPTIC TANK
A [ 0 ]Gallons MULTI- CHAMBERED /IN SERIES: [Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS @ [0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
D [ 429 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [ 0 ]SQUARE FEET SYSTEM
A TYPE SYSTEM: [ Y ]STANDARD [ N ]FILLED
I CONFIGURATION: [ N ]TRENCH [ Y ]BED
N
F LOCATION TO BENCHMARK: Garage Floor El.:11.55 Ft Ngvd
I ELEVATION OF PROPOSED SYSTEM SITE [ 3.0 ] [ INCHES
E BOTTOM OF DRAINFIELD TO BE [ 33.0 ] [ INCHES
L
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED:
TITLE:
�.
0. .
[ N ]MOUND [ N ]
[ N ]
] [ BELOW ] BENCHMARK/REFERENCE POINT
'] [ BELOW ] BENCHMARK/REFERENCE POINT
[ 72.0 ] INCHES
OTHER REMARKS:
CENTRAX #: 13 -SG -21806
DATE PAID:
FEE PAID : $
RECEIPT .
OSTDSNBR : 04 -2756- -N
1: Install 900 gals. category -1 septic tank equipped with an approved filter.
2. -The licensed contractor installing the system is responsible for installing the minimum
category of tank in accordance with sec. 64E- 6.013(3)(f), FAC.
3.- Install 429 sq. ft. of drainfield in bed configuration.
4.- Install 42" of slightly limited soil @ the bottom of drainfield.
5.- Perimeter of excavation area shall be at least 2 ft. wider and longer than the proposed
absortion bed.
6.- Invert elevation of drainfield to be no less than 9.30' NGVD.
7.- Bottom of drainfield elevation o less than 8.80' NGVD.
l
T TLE: EH Specialist I Dade CHD
EXPIRATION DATE: () O
Page 1 of 2
APPLICANT: if
'/ BLOCK:
LOT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
/ SUBDIVISION:
PROPERTY ID #: // ,� [Section /Township /Range /Parcel No. or Tax ID Number]
. r ~ t Lam. v 20 — 6:) /(7
' f►
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: /44 ACRES
TOTAL ESTIMATED SEWAGE FLOW: ',!› GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: , "j -; /') GALLONS PER DAY [1500 GPD /ACRE OR 2500 GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: ,f f, SQFT UNOBSTRUCTED AREA REQUIRED: `7,•- SQFT
u.-
BENCHMARK /REFERENCE POINT LOCATION: r j ti t t- Z ; ?t ; . , c� �% v _- c I 1 . 9 j
ELEVATION OF PROPOSED SYSTEM SITE IS %) (' : :) [INCHES /FT] [ABOVE /BELQBI] BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: (,,, /,,,t FT DITCHES /SWALES: 1N%/ A-- FT ,NORMALLY WET? [ ] YES [ii NO
WELLS: PUBLIC: /N, /,G- FT LIMITED USE: (i /h FT PRIVATE: N4, FT NON - POTABLE: ;: / FT
BUILDING FOUNDATIONS: , FT PROPERTY LINES: . `-i FT ` POTABLE WATER LINES: FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: �.(%,. FT MSL /NGVD SITE ELEVATION: / , ?,' FT MSL /NGVD
r j ✓t,/ r • "i r,
SOIL PROFILE INFORMATION SITE 1 SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture Depth
to
to
-) fd ,% to
y!"
"0 to
4 C to
!Y /1 to
' V3 / ', to
to
USDA SOIL SERIES:
EVALUATED BY:
DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used)
(Stock Number: 5744- 003 - 4015 -1)
AGENT:
PERMIT #
( / ✓ 44- / f ( 7 ' (ZG
5
10 YEAR FLOODING? [ ] YES [ ] NO
Munsell # /Color Texture Depth
01 to
n 9 ,; to
. [ .'i u to
° / to
,7""A
r \----N to
l ' ‘ to
to
USDA SOIL SERIES:
to
to
OBSERVED WATER TABLE: /-''�^ INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED t/ APPARENT]
ESTIMATED WET SEASON WATER. TABLE ELEVATION: i::/o % INCHES [ ABOVE / BELO EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ] YES [W NO ' MOTTLING: [ ] YES [V] NO DEPTH: INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: -4, -, , ' DEPTH OF EXCAVATION: INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH [ ;] BED • ] OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
DATE:
0
Page 3 of 3
APPLICANT: Frederick, Norma S.
AGENT: , OWNER
LOT: N/A BLOCK: K
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S
MUST PROVTDE REGTSTRATTON NUMBER AND STGN AND SPAT, EACH PAGE OF SUBMTTTAT,. COMPLETE AIL TTRMS.
PROPERTY SIZE CONFORMS TO SITE PLAN:[X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.14 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [64E -6, TABLE 1]
AUTHORIZED SEWAGE FLOW: 350 GALLONS PER DAY [1500GPD /ACRE OR 2500GPD /ACRE]
UNOBSTRUCTED AREA AVAILABLE: 860 SQFT UNOBSTRUCTED AREA REQUIRED: 857 SQFT
BENCHMARK /REFERENCE POINT LOCATION: Garage Floor El.:11.55 Ft Ngvd
ELEVATION OF PROPOSED SYSTEM SITE IS 3.00 [ INCHES ] [ BELOW ]BENCHMARK /REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: N/A FT DITCHES /SWALES: N/A FT NORMALLY WET? [ ]YES [ X ]NO
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: N/A FT NON - POTABLE: N/A FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 5 FT POTABLE WATER LINES: 17 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO 10 YEAR FLOODING? [ ]YES [ X ]NO
10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell # /Color Texture
1 nYR -4/1 -T1 my Rand
1 fVR - R /1 - WR. 11n1 iti r Liman
USDA SOIL SERIES: 15 Urban land
Depth
n to l6
16 to 72
to
to
to
to
to
to
OBSERVED WATER TABLE90.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [PERCHED
ESTIMATED WET SEASON WATER TABLE ELEVATION:91.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING Replacement /0.70 DEPTH OF EXCAVATION:72.0 INCHES
DRAINFIELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY)
REMARKS /ADDITIONAL CRITERIA:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
SITE EVALUATED BY: John Capers
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 003 - 4015 -1) [ostds_eval_4015 -3]
SUBDIVISION: El Portal Section 4 ID #: 11- 3206 - 020 -0010
CENTRAX #: 13 -SG -21806
OSTDSNBR : 04- 2756 -N
OWNER
SITE ELEVATION: 11 FT NGVD
SOIL PROFILE INFORMATION SITE 2
Munsell # /Color Texture
1nVR -4/1 -T rY Rand
1 fVP R /1 - WR. C1nl i ti r Liman
USDA SOIL SERIES: 15 Urban land
Depth
n to 19
1q to
to
to
to
to
to
to
DATE: 8/20/04
Page 3 of 3
•
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305 - 795 -2204
Printed: 9/20/2004
Applicant: NORMA
Owner: FREDERICK
JOB ADDRESS: 500 NE 90
Parcel # 1132060200010
Permit Status: APPLIED Permit Expiration: 3/9/2005 Construction Value:
Work: PUMP AND ABANDON BROKEN TANK
Signed:
(INSPECTOR)
Plumbing Permit
Permit Number: PL2004 -267
FREDERICK
NORMA
ST
Page 1 of 1
Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26
Local Phone: 305 - 661 -6633
Legal Description: EL PORTAL SEC 4 PB 12 -56 ALL
BLK K LOT SIZE SITE VALUE OR
Fees:
FEE2004 -9387
FEE2004 -9388
FEE2004 -9389
FEE2004 -9390
FEE2004 -9391
Description
Building Fee
CCF
Notary Fee
Training and Education Fee
Technology Fee
Total Fees:
Amount
$175.00
$0.60
$5.00
$0.20
$4.37
$185.17
Total Fees: $185.17
Total Receipts: $0.00
$50.00
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
•
BUILDING
PERMIT APPLICATION
FBC 2001
Contractor's Address 3Y1:;
City u ■-ra fv^
Qualifier \ e1 eso SC
Architect/Engineer's Name (if applicable)
(Continued on opposite side)
_Miami Shores Village
T ` s r, r TA- ' ;Building De artment
iB g p
\ 3EP 1 0 ?. 11050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit Type (circle): Building Electrical um j n Mechanical Roofing
Owner's Name (Fee Simple Titleholder) 1.1r.) ir , t = { <j e,/ ( C K_ Phone # ( i i_S> 7 �; j -. ci 3 4f,'
Owner's Address 500 1' e cici �' /
City M , G r- S i'kti reS State L. Zip 531 3e
Tenant/Lessee Name t 9 : 4 r-4 ) Phone #
Job Address (where the work is being done) % Nit (a 0 r e Z
City Miami Shores Village County Miami -Dade Zi . l
Is Building Historically Designated YES NO t
Contractor's Company Name 5 V.A rare. 1 C' Wry wr,} o # � ,� '(' (' 33
State
2_G
Permit Noo1-, 0 y
Master Permit No.
Zip 3SC 2,
k) Phone #
o0
$ Value of Work For this Permit DJ �,a Square Footage Of Work:
Type of Work: El Addition ❑Alteration 51New ❑ Repair/Replace ❑ Demolition
Describe Work: "� qtr }.;�e�: vt k. s }. €Afr.1 O cep 1r)1 -E' .o).
* * * * * * * * * * * * * * * * * * * * * * * * * * ** F ees * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ 1'7 .S ' CCF $ ! / 0 coicC
Notary $S,' 0 Training/Education Fee $ / , a b Technology Fee $
Scanning $ Radon $ Zoning Bond Si o 0
Code Enforcement $ Structural Plan Review. $
Total Fee Now Due $ L �' ` .
Bonding Company's Name (if applicable)
Bonding Company's Address r J A
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address PIA
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 ELECTRICAL WORK, PLUMBING, SIGNS,
WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and 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 brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement 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 reins •ection fee will be charged.
Signature ��� Si �C ` \QS CO�'� -0�
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this 6 The for oing instrument was .. awledged bi re me this J 0
day of j1 , 20 , by IL/ °{ rr p '` Cig-' , day o , 20\( • % ► ' ,'ill 1144►6.v
who is personally known to me or who has arodu
NOTARY PUBLIC:
Sign:
Print:
My Commiss} n Exp • s:
State Certificate or Registration No.
Chc 12/15/03
AS, ti� IC�p lke oath. a - identificati s' . d who did take an oath.
''" e ot MY COMMISSION #t D13250437 ► NOTARY P
nix
September 16, 2007
,J Discount Assoc. Co.
"�� Print:
(Certificate of Competency Holder)
My Commission Expires:
Certificate of Competency No.
who is personally known to me or who has produced
►Av .nmmission DD150048
x 0Ires I'1ovemUer I D,,euOo
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * *- ************************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
APPLICATION APPROVED ITY: �' lam/( /' ������j ` 7 Plans Examiner
Engineer
Zoning
Miami Shores Village
10050 NE 2nd Avenue
Plumbing Permit
Phone: 305 - 795 -2204 Permit Number: PL2004 -266
Printed: 9/20/2004
Applicant: NORMA FREDERICK
Owner: FREDERICK NORMA
JOB ADDRESS: 500 NE 90 ST
Page 1 of 1
Contractor STATEWIDE SEPTIC CONNECTIONS Contractor's Address: 3590 SOUTH STATE ROAD 7, SUITE 26
Local Phone: 305 - 661 -6633
Parcel # 1132060200010
Signed:
Legal Description: EL PORTAL SEC 4 PB 12 -56 ALL
Permit Status: APPROVED Permit Expiration: 3/9/2005 Construction Value: $2,000.00
Work: INSTALL NEW TANK AND NEW DRAINFIELD
(INSPECTOR)
BLK K LOT SIZE SITE VALUE OR
Fees: Description Amount
FEE2004 -9381 Building Fee $175.00
FEE2004 -9382 CCF $1.20
FEE2004 -9383 Notary Fee $5.00
FEE2004 -9384 Technology Fee $4.37
FEE2004 -9385 Training and Education Fee $1.20
FEE2004 -9386 Builders Bond $300.00
Total Fees: $486.77
Total Fees: $486.77
Total Receipts: $0.00
4S
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work
done by either myself, my agent, servants or employes.
• Signed: (Contractor or Builder) BY:
APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONS ITE SEWAGE TREATMENT
CONSTRUCTION INSPECTION
AGENT:
PROPERTY ADDRESS: 5— P c
LOT:' ' BLOCK: i \ SUBDIVISION: - '
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION F ,
[01] TANK SIZE [1] /' »" [2]
[02] TANK MATERIAL (` <-r -f
[03 ]
[04]
[05]
[06 ]
[07 ] WATERTIGHT
[08] LEVEL G ✓r , /
[09] DEPTH TO LID Y r
FILL
[22 ]
[23 ]
[24]
[25]
[26]
OUTLET DEVICE i
MULTI CHAMBERED [(Y)/ N ]
OUTLET FILTER
(
LEGEND �,. ° "r;
v c =-
DRAINFIELD INSTALLATION
[10] AREA [1] it )1 A [2] P SQFT
[11] DISTRIBUTION BOX HEADER
[12] NUMBER OF DRAINLINES
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER /-?,
[16] ELEVATION [ABOVE /BELOW] BM
[17] SYSTEM LOCATION ; [18] DOSING DOSING PUMPS IV
[19] AGGREGATE SIZE's ? ': 4 ' 1a'
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPTH O= °
/ EXCAVATION MATERIAL
FILL AMOUNT a�
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
d
AND
AND
FINAL
t>
4
CONSTRUCTIO T APPROVEDiDISAPPROVED] :
FINAL SYSTEM APPROVR ( /DISAPPROVED ] :%���1t %/ `-
/�{
DH 4016, 10/97 (Previous Editions May Be Used)
PERMIT NO
DATE PAID:
DISPOSAL SYSTEM FEE PAID: •)':l
APPROVAL RECEIPT #:
PROPERTY ID #:
SETBACKS
]
[27] SURFACE WATER g � FT
] [28] DITCHES FT
] [29] PRIVATE WELLS FT
] [30] PUBLIC WELLS FT
] [ 31] IRRIGATION WELLS FT
] [32] POTABLE WATER LINES f/7✓ FT
] [33] BUILDING FOUNDATION FT
] [34] PROPERTY LINES i FT
] [35] OTHER FT
FILLED / MOUND SYSTEM
] [36] DRAINFIELD COVER
] [37] SHOULDERS
] [38] SLOPES
] [39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SIZE PLAN
[46] FINAL SIZE GRADING ?
[47 ] CONTRACTOR.
[48] OTHER
ABANDONMENT
[ ] [49] TANK PUMPED / -' / � / 0 1
[ ] [50 ] TANK CRUSHED & FILLED /f) /A / Fes
PT 1: Applicant
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
CHD DATE:' 0
CHD 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)
SET BACKS (record actual setbacks in ft)
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:
CONSTRUCTION APPROVAL:
AS BUILT INSTALLATION SKETCH
Record item number, explanation of violation, and required.
Circle approved or disapproved, CHD signature and date.
FINAL APPROVAL: Circle 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 specifications submitted with permit application.
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