05-1213-000ELEVATION OF PROPOSED S STEM SITE IS /[IN ES /F'T] (ABOVE /BELOW) BENCBD'fARR /REEKBASf oAIN
THE MINIMUM SETBACK WHI
SURFACE WATER:
WELLS: PUBLIC:
BUILDING FOUNDATIONS:
'6ITE SUBJECT TO FREQUEN
YEAR FLOOD ELEVATION
H CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE I'OLLOWING FEATUREftl
T DITCHES /SWALES: kf FT NORMALLY WET? ( ) YES/ (' N
T LIMITED USE: e_ FT PRI�: rl FT NOV- POTABLE: '/ F
FT PROPERTY LINES: 4 FT POTABLE WATER LINES: 6A F
/D
��
FLOODING: ) YES (v) NO 10 YEAR FLOODING? [ J YES ( ] N
FOR SITE: _5 5 FT MSL /NGVD SITE ELEVATION: 6' � FT MSL /NGV
.SOIL PROFILE INFORMATIO1 SITE 1
,I
• r
s
USDA SOIL SERIES:
Depth
�r1 to
to
.V"-to
to
to
to
to
to
to
SOIL PROFILE INFORMATION SSITE 2
Mu s o Textuxe Depth
l r
3.1-3 ` !— En to
P4 1 to
/ L v VIC to
to
to
to
to
l -rM9 to
USDA SOIL SERIES: li.u�D
OBSERVED WATER TABLE: JZ p" INCHES (ABOVE / BELOW EXISTING GRADE. TYPE: (PERCHED / AEP88L'f[T
ESTIMATED WET SEASON WA R TABLE ELEVATIO C: �HES [ ABOVE / BF, I-W J EX IS g GRADE
HIGH WATER TABLE VEGETA ION: [ ) YES (jNO MOTTLING: [ ) YES (�NO I'-EPTH: INCHE
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: 1j �L I[-1 DEPTH OF EXCAVATION: �� INCHE
DRAINFIELD CONFIGURATION: [ ] T NCH (] BED ( ] HER (SPEC FY)
REMARKS/ ADDITIONAL CRITERIA:
SITE EVALUATED BY : vl�•L -DATE:
1
Page 3 of
DN 4015. 10/96 (Reputes HRS. H rm 4015 [P l. 31 which may be used)
(Stock Number 5744-003-4015-1)
40P
OS-1 7,15
Q" STATE O
FLORIDA PERMIT
DEPARTMENT
OF HEALTH
Pf ONSITE SEWAGE
DISPOSAL SYSTEM
.
' SITE EVALUATION
AND SYSTEM SPECIFICATIONS
goo „,r v
APPLICANT.
AGENTt �
M
LOT: BLOCK:
/ SUBDIVISION: '�
PROPERTY ID 1: &3
_ o q' _� � [Section /Township /Range /Parcel Mc,.
T
or Tax ID Number
--- --- x--- --- ---- - - - ---
cccxse= xs.. oocnc= cc. c=== xxa= xxxaxxs_ xsxx= _xxx.csaaaao= asoxtsxssx3asxxx ==
TO BE COMPLETED BY ENGII
BER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON.
ENGINEER'S MUS
PROVIDE REGISTRATION
ER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLp;TE ALL ITEMS.
== oxxccxx��c=== o_ ______
______ cxc= =xxxx= === x.. x== ecnsscsxssxssxxscxxaxoasssa .xaxsxsxssssx - - - -an
PROPERTY SIZE CONFORMS
O SITE PLAN: ( YES ( ) NO NET USABLE AREA AVAIL13LE: F). % ACRE
TOTAL ESTIMATED SEWAGE
OW: o GALLONS PER DAY (RESIDENCES- TABLP;
LE 1 / OTHER -TAB 2
AUTHORIZED SEWAGE FLOW:
(0ej GALLONS PER DAY 11500 GPD /ACRE Oj-- _ 2500 OPD /ACRE)
UNOBSTRUCTED AREA AV
LE: 1(p e'C, SQFT UNOBSTRUCTED AREA REQUIRED:
66U SQF
---f
BENCHMARK /REFERENCE POI
T LOCATION: c.f1 4'J
ELEVATION OF PROPOSED S STEM SITE IS /[IN ES /F'T] (ABOVE /BELOW) BENCBD'fARR /REEKBASf oAIN
THE MINIMUM SETBACK WHI
SURFACE WATER:
WELLS: PUBLIC:
BUILDING FOUNDATIONS:
'6ITE SUBJECT TO FREQUEN
YEAR FLOOD ELEVATION
H CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE I'OLLOWING FEATUREftl
T DITCHES /SWALES: kf FT NORMALLY WET? ( ) YES/ (' N
T LIMITED USE: e_ FT PRI�: rl FT NOV- POTABLE: '/ F
FT PROPERTY LINES: 4 FT POTABLE WATER LINES: 6A F
/D
��
FLOODING: ) YES (v) NO 10 YEAR FLOODING? [ J YES ( ] N
FOR SITE: _5 5 FT MSL /NGVD SITE ELEVATION: 6' � FT MSL /NGV
.SOIL PROFILE INFORMATIO1 SITE 1
,I
• r
s
USDA SOIL SERIES:
Depth
�r1 to
to
.V"-to
to
to
to
to
to
to
SOIL PROFILE INFORMATION SSITE 2
Mu s o Textuxe Depth
l r
3.1-3 ` !— En to
P4 1 to
/ L v VIC to
to
to
to
to
l -rM9 to
USDA SOIL SERIES: li.u�D
OBSERVED WATER TABLE: JZ p" INCHES (ABOVE / BELOW EXISTING GRADE. TYPE: (PERCHED / AEP88L'f[T
ESTIMATED WET SEASON WA R TABLE ELEVATIO C: �HES [ ABOVE / BF, I-W J EX IS g GRADE
HIGH WATER TABLE VEGETA ION: [ ) YES (jNO MOTTLING: [ ) YES (�NO I'-EPTH: INCHE
SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: 1j �L I[-1 DEPTH OF EXCAVATION: �� INCHE
DRAINFIELD CONFIGURATION: [ ] T NCH (] BED ( ] HER (SPEC FY)
REMARKS/ ADDITIONAL CRITERIA:
SITE EVALUATED BY : vl�•L -DATE:
1
Page 3 of
DN 4015. 10/96 (Reputes HRS. H rm 4015 [P l. 31 which may be used)
(Stock Number 5744-003-4015-1)
Ji . =T
' r
APPLICATION FOR:
[ ] NOW System
( ] Repair
APPLICANT:
OF FLORIDA
:ENT- OF HFALTH
SE MGM TR RAT Wr AND DISPOSAL
ATION FOR CONSTRUCTION PERMIT
[X11" Existing System [ ] Holding Tank
[ ] Abandoi6mnt [ ] Temporary
PERMr'i' NO.
DATE PAID:
FEE PAID:
RECEI7 7 #:
[ ] innovative
AGENT: I y - I - �IJ TELEPHONE "(- � "ej
MAILING ADDRESS: I I ; Y1, I i E q 3
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TO 88 C01IDpL8=== BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTMKS MIDST BE CONSTRUCTED
BY A PERSON LI r 0 IS D PURSUAIfr TO 489.105 (3) (m) OR 489. S S 2 , FLORIDA STATU'R'ES. IT I3 Tim
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUIDBZITATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (M /DD /YY) IF REQDSSTINb CONSIDERATION OF STATUTORY GRAM1DFATMM !PROVISIONS.
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PROPERTY INPORIIATI
LOT: �_ BLOCKj 9 SUBDIVISION: 6*-CiVal ea) )� �n4- ,-5 PLATTED: I95
PROPERTY rn 0 : - LI (/ 3(C - - S Q ZONING: I /M OR EOUI VALElTr : I Y /,X-11
PROPERTY SIZE: GT ACRES WATER SUPPLY: I l PRIVATE PUBLIC IVJ < =20110GPD ( ) >20009PD
IS SEVER AVAILABLE PER 3881.0065L, FS? [ Y / W-< DISTANCE TO SEWER: FT
PROPERTY ADDRESS e AS5-1ye;1 % J a j 11?!� J T L {mil -1 , -k-, � ),- An:' I
DIRECTIONS TO
BUILDING XNFORMATIO
Unit Type of
No Establishmsnt
1 -� r
OA
3
4
[VI RESIDENTIAL I ] COQ RCIAL
No. of Building Commercial/ Ina titutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E -6, FAC
3/a I C,cA
Floor /Equi t Drains (Pi ] Other (Specify)
1z �/
SI(RiATURE:
7
DATE:
CONTRACTOR / ARREST: Q
LOT:
= mvammaammamamavaamm
TO BB COKPLETE) BY F
OTHER CERTIFIED PERS
COMPLETE TAM CRRTIF
mmamamemammmammaamvv
EZISTZKO TANK INFORN
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SIIBDIV : I D$ : 69- yQ.i6 '(J4
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RID]► RBQISTXRHD ENOIIMt, DEPART=NT ffiLOYEt, SEPTIC 750K CONTRACTOR OR
. SIGN AND SEAL ALL SDBilXTTBD DOCUMENTS. COIP LSTB ALL APPLICABLE ITEMS.
LTION BELOW OR ATTACH LETTER FROK A PERMQTrZD SEPTAGE D:CSPOSAL SERVICE.
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aAla.Ow C TANK /(BPD ATQ LBGRED: MATERIAL: a�- 1IL);( BAFFLED: [Y / N)
[ ) GALLONS C TALK /GPD ATQ LBGMKD: MATERIAL: _ BAFFLED: ty / NI
[ ]
GALLONS ZNZE:CE'rDR L GMKDa MATERIAL:
[ I GALLONS DOS TALK LEGEND: MATERIAL : _ # PUMPS:
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I CSRTIPY THAT HOTS) TAMIMLS 11ERB PL)!II►ED ON 7/ /S/ C`�> JMVB THE YOLiIll8.9 SPSCIPIlE, ARE
STRIIClQRAI.LY . HAVE A I SOLIDS D pm ODLS! FILTH DSV]_CE, ] INSTALLED.
SIOKATU RR O CTOR BUSINESS DATE
maammmmmmmmda aaamam mamaaaamamansammma amvmvnmadbammevvs aaammammnm avmvaaammemanmmamvmmmamaamav
EXISTING D TIAf
SOMME FEET PU31LRY DRAINFIEI.D SYSTEI NO. OF TR8KCSES I ] DUDES] OHS : 1)/ %
I ]
SQUARE FEET SYSTEM NO. OF TRENCHES [ ) D17IENSIONS: x
TYPE OF SYSTEM: [ ) STANDARD [ VFILLEfl I ) 18 E [ )
CONFIQORATION: I TREMCS [ I BBD [ ]�
DBSIIE: [ ) HEADER [ I D -Boa MhvIT! SYSTEK [ l DOSED SYSTEMS
ELEVATION OF BOTTOK CF DRA.IIMFIE.D IN RZX ATION TO RXXSTNIW+O GRADE XNCnS [ ABOVE / BELOW)
] - SYSTEM FAILURE AM
SYSTEM
[ _ ] GM IW
SITE [ ^ I D]
coNDI:TiONS: [l ]
SATURN OF IJ1 ]
FAILURE: Lr L ]
FAILURE I )
SYM PTOK: [Al
SUBIRIITE) BY:
I
DR 4015, 10/9,
IIMP�ORIATION
ATION DATE TYPE O [ ] DOLKSTIC ( ] CONXMCIAL
SEMA(K FLOW BASED ON lk ) IATBRED WATER I ] TABLE 1, 645 -6, FAC
STRUCTURES POOL [ ] PATIO / DECK [ ] PA BMW
PROPERTY
OVERLOAD I i l SOILS MAIIMTRNMKZ
/ RUN OFF I K ] ROOTS WATER TABLE
on GROG [ /!, TANK
G BACKM?
D BOZ/HRADER
, I SY M= DANAGE
[ DRIL131FIELD
TrTLE/Lrcimb I `x / �� '� % _DATE:.]
Editions may be used)
Page 4 of 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION F C R ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
--------------------------- PART II - SITEPLAN ---------------------------
Scale: Each bbdc represents 10 feet and 1 inch = 40 feet
-- 4
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Site Plan submitted by:
Plan Approved Not Approved Date
By G )unty Health Depart"
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPAI1TMENT
DH 4015. 10195 (Rephices HRS-H 4016 which may be used) Page 2 t
(Slod( Mmber. 5744 - 0024015 -6)
FLORIDA DEPARTMENT OF
HEZr
WELL FORM
Chapter p4E- 6.004(3)(a) F A C
DOH #
A plan or plat of the lot or total site ownership drawn to scale, showing boundaries with
dimensio as, locations of any existing or proposed residences or buildings, swnnming pools,
recorded easements, the onsite sewage treatment and disposal system compon --nts and their
location en the property, the slope of the property and any existing or proposed wells, potable
and non- table water lines, including valves, drainage features, filled areas, uiobstructed
areas, an I surface waters bodies. The site plan shall indicate the location of wills, onsite
sewage t eatment and disposal systems, surface waters and other pertinent facilities or features
on cunt' uous or adjacent property. If the features are within 75 feet of the applicant lot, the
estimatec distance to the feature must also be shown but need not be drawn to scale. The
location 4 of any public drinking water well, as defined in Rule 64E- 6.002(44)(b), within 200
feet oft applicant's lot shall also be shown, with the distance indicated from the system to
the well, uid the location of limited use public water system or other public wells, as defined in
Chapter E- 6.002(44)(b), within 100 feet of the applicant lot must also be sb)wn, or as
defined ii Chapter 64E- 6.002(44)(a), F.A.C., within 75 feet from a private potable water well
(well uso only by one or two residences).
Chapter P4- 12(18) Miami -Dade County Code:
The i ' um separation between a well or wells and possible sources of contamination shall
be a function of the drawdown and radius of influence of the well or wells. In io case shall the
well be lowed less than one hundred (100) horizontal feet from any source of :ontamination.
I have r the above and to the best my knowledge I have provided the Department with full
informatit n regarding pertinent facilities and features on all adjacent properties. Furthermore, I
understand that any onsite sewage treatment and disposal system permit issued on the basis of
said facili ies and features as provided by me and found to be incorrect Hall be subject to
revocatioq in accordance with the provisions of chapter 120, Florida Statutes.
Date: / � / 2006 Signature 2e