PL-10-1137Inspection Number: INSP- 146622 Permit Number: PL -6 -10 -1137
Scheduled Inspection Date: April 18, 2011
Inspector: Hernandez, Rafael
Owner: CLAVERIA, LILLIAN
Job Address: 304 NE 99 Street
Project: <NONE>
Miami Shores, FL
Contractor: STATEWIDE SEPTIC CONNECTIONS
Building Department Comments
April 15, 2011
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
For Inspections please call: (305)762 -4949
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060135600
Phone: (954)963 -0082
ABANDON SEPTIC /NEW TANK AND DRAINFIEL
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
Page 2 of 27
BUILDING
PERMIT APPLICATION
FBC 200$
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
Permit No.
Master Permit No.
11_ —1C .;I
Permit Type: Plumbing /—�
Owner's Name (Fee Simple Titleholder) 0 /b 5 Phone # 3 O S - 7S - 2 - 7 7 SJ
Owner's Address `50 I Oj S
Cit 01 I /c\,✓l, 1 S 2c' State P L. Zip ' 3 13
Tenant /Lessee Name Phone #
E -MAIL:
Job Address (where the work is being done) 3o 4 me. 9 + j sT
City Miami Shores Village County Miami -Dade Zip 331 3 8
FOLIO /PARCEL# 11-32_0e- o -_+ Qo
Is Building Historically Designated YES NO
an Name ��'
p Y +e ��'de Z I `�� Cm, ,S'
Contractor's Company Phone # G6 l- '63_3
Contractor's Address 3590; c-r► Z
State Zip - 0 23
Qualifier Name T€res'; t Phone #
Type of Work: ❑Addition
Describe Work:
State Certificate or Registration No. S i t . ' '� 1 n 'Z
E -MAIL:
Certificate of Competency No.
Architect /Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ Square / Linear Footage Of Work: 3 Oa
❑Alteration ['New ! X Repair /Replace ❑ Demolition
goo a c Iran S-r c4or
►pct 041 - Pac' - t - �l . f )t
' civ ic * ***.****ie****'.c* ******* isi:r.r. ic*r. *i: r, r.*** Feeswwwwwxxr. xxxxxxxxxx: to :wwwwww.wxi:x*i:i:wwwr.w**wwww
Submittal Fee $ Permit Fee $ CCF $ CO /CC
Notary $ Training /Education Fee $ Technology Fee $
Scanning $ Radon $ DPBR $ Zoning $
Bond $ Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $
See Reverse side -*
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City State Zip
1
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. 1 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: 1 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 WITEI 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 properly 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 app oved and reinspection fee will be charged.
(Revised 02/08/06)
APPLICATION APPROVED BY:
Signature Signature
Owner or Agent 2 Contractor
The foregoing instrument was acknowledged before me this 13 The foregoing instrument was acknowledged before me this
day of t 1rt_tL, 20 ( by (H t� F�C.2.0 It . day of
, y , 20 , by
who is personally known to me or who has produced ft---1 who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC: \ \ \ 00 011,11N0 0, / � j ��
NOTARY PUBLIC:
Sign: _'
_ Sign:
Print: _ M al V
Print:
My Commission Expires:
Z�OZ19
y p 6' a tia'',�?' �\� My Commission Expires:
\��
#r.xxxxxxxxxxxx xxxxx x x eex****xat � .ytemir s. e.tck x xi***w xx*www* xxxx *xxr. xee r. xaerxxr, r, r. r. r. iex
Plans Examiner
Engineer
Zoning
ealth Des a men
�� IVISio
iami 3 75
APPLICANT: Lillian Claveria
AGENT: Statewide
PROPERTY ADDRESS: 304 NE 99 St Miami, FL 33138
LOT: 11 - BLOCK: 41
SUBDIVISION:
[ ] [10] AREA [1] 675 [2] SQFT [ ] (36] DRAINFIELD COVER
[ J [11] DISTRIBUTION BOX HEADER X [ ] (37] SHOULDERS
[ ] [12] NUMBER OF DRAINLINES 1. 7.00 2. ( ] [38] SLOPES
[ ] [13] DRAINLINE SEPARATION ( ] [39] STABILIZATION
[ ] [14) DRAINLINE SLOPE
[ ] [15) DEPTH OF COVER ADDITIONAL INFORMATION
[ ] [16) ELEVATION [ ABOVE /1 BELOW I 118 57.84 [ J [40] UNOBSTRUCTED AREA
( ] [17] SYSTEM LOCATION ( ] [41] STORMWATER RUNOFF
[ ] [18] DOSING PUMPS ( ] [42] ALARMS
[ ] [19] AGGREGATE SIZE ( ] [43] MAINTENANCE AGREEMENT
[ J (20) AGGREGATE EXCESSIVE FINES ( J [44] BUILDING AREA
[ ] [21] AGGREGATE DEPTH [ ] [45] LOCATION CONFORMS WITH SITE PLAN
FILL / EXCAVATION MATERIAL ( ] [46] FINAL SITE GRADING
[ ] [ 22) FILL AMOUNT ( ] [ 47 ] CONTRACTOR Teresa J Solomon (Statewide
[ ] [23] FILL TEXTURE ( J [48] OTHER ARDS ARC 24
[ ] [24] EXCAVATION DEPTH ABANDONMENT
[ ] [25] AREA REPLACED [ ] [49] TANK PUMPED
[ ] (26) REPLACEMENT MATERIAL [ ] (50) TANK CRUSHED & FILLED
Comments: Comments are on page 2.
CONSTRUCTION [
FINAL SYSTEM
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION SETBACKS
[01] TANK SIZE [1] 1050.00 [2]
[ 02) TANK MATERIAL Concrete
[03] OUTLET DEVICE
[04] MULTI- CHAMBERED [I Y N
[05) OUTLET FILTER Zabel
[06] LEGEND 1. 13 076 - 08DC3 2.
[07] WATERTIGHT
[08] LEVEL
[09] DEPTH TO LID
DRAINFIELD INSTALLATION
[
APPROVED
I APPROVED I
(Explanation of Violations on following page)
Miami Shores ID #: 11- 3206 - 013 -5600
/
FILLED / MOUND SYSTEM
Dade
DISAPPROVED ] Ronald E Cave (Dade County Environmental Health)
/ DISAPPROVED ]:
Ronald E Cave (Dade County Environmental Health)
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
EH Database v 1.0.1 AP969467 EID1148775
APPLICATION # :AP969467
PERMIT # :13 - SC - 1148775
DOCUMENT # : F1796242
DATE PAID: 06/18/2010
FEE PAID:
RECEIPT #:13 -PID- 1276550
[27] SURFACE WATER
[28) DITCHES
[29] PRIVATE WELLS
[30] PUBLIC WELLS
[31) IRRIGATION WELLS
[32] POTABLE WATER
[33] BUILDING FOUNDATIONS
[34] PROPERTY LINES
[35] OTHER
CHD
FT
FT
FT
FT
FT
50 FT
6 FT
5 FT
FT
DATE: 07/02/2010
Dade CHD DATE: 07/07/2010
Page 2 of 3
DIVISION OF
Environmental Health
F lorida Department of Health
M iami = Dade County Health Department
OSTDS /Well Division
11805 SW 26 St. • Miami, FL 33175
Inspector Date 7 2 " 0/ a
Address _3 G / ../V . Y/ OSTOS # / 1' S
Gomm ts:
Owner's Address
Contact Phone
Tenant/Lessee Name
Email
BUILDING
PERMIT APPLICATION
FBC 20
Permit Type: PLUMBING
Owner's Name (Fee Simple Titleholder)
Qualifier Name r e r-e c.
304- NC. i4
" JA
FOLIO / PARCEL # k 2.. • D l 3 — c( 0 0
Contractor's Company Name
Contractor's Address 39 c ., S-1- 0 4 7 *26
City 1-01% fla"MCr
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
City !k► A./A t 5WrkF State FL. Zip 33 1 3 y
L t i ti eul
Job Address (where the work is being done) C 4 / Oyj
City Miami Shores Villaee County Miami -Dade
Is Building Historically Designated YES NO J<
State
(2-
i ..- y tani L.
C:��� Phone# 8 S - .`3 CI = LL 7
State Certificate or Registration No. S -h cr1 t 2 G 2 Certificate of Competency No.
E -mail
Permit No.
Master Permit No.
d B.'S
Phone #
Phone #
� �GF�BNI3�
JUN z z zoio
BY: .
Zip 331'31
Flood Zone
Phone # 3 4 36 / - 6 6 3 -
Architect /Engineer's Name (if applicable) i lib►Z B i..AJO Phone # ti • J �� . . S2
Value of Work For this Permit $ 5; C;'G f Square / Linear Footage Of Work: 667
Type of Work: ❑Addition ['Alteration ❑New Xj Repair /Replace ❑ Demolition
Describe Work: p ,.,., bye, rC i a7/t
(4(( €F.uf +a.n k 4 f' .1 D ✓4','rl e t dr
******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** F * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Submittal Fee $ Permit Fee $ �G6 CCF $ CO /CC $
Notary $ Training /Education Fee $ 1' Technology Fee $ 4.1.c
Scanning $ 1/4. ` •` Radon $ DPBR $ Bond $
Double Fee $ Violation date:
Structural Review. $ Total Fee Now Due $
See Reverse side —>
/D - //;7
Bonding Company's Name (if applicable) N / 4
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) j q I (A
Mortgage', Lender's Address
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 reinspection fee will be charged.
Signature �J'(�,�b L' LJ�^�..
Owner or Agent / Contractor
The forego ill instrument was acknowledged before me this !62 Ill The foregoing instrument was acknowledged before me this
day of Ll r 20 /) , by , Ju tin fi74 S , day of — C , 20 IQ by 6-0- - S {�Yrik9 h
who is p r'sonally known j me or who has produced .,1)k who is personally known to me or who has produced
as identification and who did take an oath.
As identification and who did take an oath.
NOTARY, PUJ LIC:
Sign:
Print:
My Co
mission. Expires:
11 %L " / /I
APPROVED BY
(Revised 07 /10 /07)(Revised 06/10/2009)
. 9.4( ,
�* : p p 63014 4 , :
% yam 4b sondeatO • • tit,
h ilt s': t�i ***************** *k :Fi:d:k9:*** **********k9: ****9: :F * k9; 9; 9; *** **** *:F**
OBLIC, P� 0.,
Py #II
Plans Examiner Zoning
Engineer
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
Clerk checked
T
H
E
R
STATE OF FLORIDA APPLICATION #: AP969467
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID:
SYSTEM
RECEIPT #:
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Lillian Claveria
PROPERTY ADDRESS: 304 NE 99 St
LOT: 11 - BLOCK: 41 SUBDIVISION: Miami Shores
PROPERTY ID #: 11 - 3206 - 013 - 5600
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT 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.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 900 ] GALLONS / GPD Seam CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K ( ] GALLONS DOSING TANK CAPACITY ( ]GALLONS Q( ]DOSES PER 24 HRS #Pumps [ ]
D [ 300 ] SQUARE FEET SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [X] BED [ ]
N
F LOCATION OF BENCHMARK: F.F.E.: 12.50' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 26.40 (I INCHES I- FT 1[ ABOVE /I BELOWbBENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 62.40 ] [ INCHES I FT 1 ( ABOVE A BELOW b BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED:
SPECIFICATIONS BY:
DATE ISSUED:
[ 0.00 ] INCHES
1— Install 900 gal. category-3 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). 3- Install 300 sf of
drainfield in bed configuration. 4- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed
absorption bed. 5 -Invert elevation of drainfield to be no less than 7.80' NGVD l rp drfil Ration to be no
Tess than 7.30' NGVD.
MIAM•DAf COUNTY HEATH DEPARTMENT
T
THIS PERMIT IS NOT FOR ADDITION(s
Miami, FL 33138
EXCAVATION REQUIRED:
ITLE:
sp ina
06/21/2010 1 EXPIRATION DATE: 09/19/2010
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1.1 .4
AP969467
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
[ 36.00 ] INCHES
SE820062
PERMIT #: 13-SC-1148775
DOCUMENT #: PR813857
Page 1 of 3
CHD
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS Abandonment
APPLICANT: Lillian & John Claveria Korbes
PROPERTY ADDRESS: 304 NE 99 St Miami, FL 33138
LOT: 11 -12
PROPERTY ID #: 11- 3206 - 013 -5600
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT 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.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
BLOCK: 41 SUBDIVISION: Miami Shores
T ( ] GALLONS / GPD CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ ] SQUARE FEET SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [ 1 STANDARD [ ] FILLED [ 1 MOUND [ ]
I CONFIGURATION: [ 1 TRENCH [ ] BED [ 1
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [ ][ / ][ ABOVE/BELOW 1BENCHMARK/HEFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ ][ / ][ABOVE/ BELOW ]BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES
T
H
E
R
Have the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of
the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The
tank shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system inspected
by the health department after it has been pumped and ruptured but before it is filled with sand and covered.
SPECIFICATIONS B
APPROVE BY:
DATE ISSUED:
PED
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
EXCAVATION REQUIRED: [ ] INCHES
TITLE Dade cap
Po • o N Oapina
06/21/2010 EXPIRATION DATE: 09/19/2010
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1 .1.4
AP969462 SE -1
PERMIT #: 13-SC-1148768
APPLICATION # : AP969462
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR813852
Page 1 of 3
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes:
xi x2 9„1.1 11,00t
1.
4
(N 9 9 S
30 NE M Shock- 331
? -1 P tt A-P,A1a3nl S Y>Tl G T q-r-1 K—
Site Plan submitted by:
gna
Plan Approved Not
By
DH 4015.10/08 (Replaces HRS-H Form 4015 which may be used)
(Stoic Number: 5144002.4015.81
cAlf-e-j
p .... eti t te t 204
too
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN - -L- = c
I ld STA l.I. NIENJ "T - D Ra rI E ON 14 .
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
c� ►strzeNi.Taa_
Title
Date
County Health Department
Paae 2 of 3
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Notes:
DH 4015.10198 (Replaces HRS44 Form 4015 which may be used)
(Stock Hunter: 5744-002-40154)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
° APPrICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
,
PART II SITE PLAN
./ it (/-
N c ct
Nr qci Sr 531
° 0A-Y1 p Ato4.-Ndoel hr-io Ican c
4 4 2 '2pcI
rfi
fNi
Site Plan submitted by:
Signature
Plan Approved NotAppraved----' Date
2.4a) County Health Department
ALL CHANGES Mr* BEAPPAOVED BY THE COUNTY HEALTH DEPARTMENT
Page 2 of 3