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PL-05-255Miami Shores Village 10050 NE 2nd Avenue Phone: 305 - 795 -2204 Printed: 8/16/2005 Applicant: HUGETTE Owner: GRUNDER JOB ADDRESS: 90 NW 110 Plumbing Permit Permit Number: PL2005 -255 GRUNDER HUGETTE ST Contractor THE NEW MIAMI SHORES PLUMBING Contractor's Address: 900 NW 144 ST Local Phone: 786- 553 -5424 Parcel # 1121360030080 Fees: Description Amount FEE2005 -11189 Building Fee $175.00 FEE2005 -11190 CCF $1.80 FEE2005 -11191 Training and Education Fee $0.60 FEE2005 -11192 Technology Fee $4.40 FEE2005 -11193 Scanning Fee $3.00 FEE2005 -11194 Builders Bond $300.00 Total Fees: $484.80 Total Fees: $484.80 Total Receipts: $0.00 Permit Status: APPROVED Permit Expiration: 2/8 /2006 Construction Value: $2,400.00 Work: INSTALL NEW DRAINFIELD Signed: Legal Description: 36 52 41 MIAMI SHORES EXT PB 43-40 LOT 8 BLK 219 LOT SIZE (INSPECTOR) Page 1 of 1 PUG 1 7 PAI® err cx:. 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: 3608 nif MIAMI SHORES VILLAGE t- BUILDING DEPARTMENT �O�►�fi 305- 795 -2204 Building Inspection Request Date �241os Type Insp'n C tI fl yid tlOvtL, Permit No. "71- 2 J - 2.55 Name �U�C1t ( Address . q0 NW 110 T la Nt i tka)kt 1 /'G 'RU 4JJ 1 rte. Phone # I8{) 555 '541-4 Inspection Date Approved Correction Re- Insp'n Fee J t UUUs. BUILDING Permit No' J -2_55 PERMIT APPLICATION aster Permit No. - FBC 2001 ��r��_ / A /l •g ' ' WJ 'WRJ Permit Type (circle): Building Electrical „° PPlumbing i/ Mechanical Roofing Owner's Name (Fee Simple Titleholder) WC e,rund Phone # J 15 ' 1 Owner's Address RO Ng 1 10 City MOOm' Shores. State fl ' Zip 3 >/, Tenant/Lessee Name Phone # Job Address (where the work is being done) qO NL HO Sl e City Miami Shores Village Is Building Historically Designated YES NO Contractor's Company Name AfeW 44/4 4G Contractor's Address 9 Ae /y4 City MI Q'ni State Qualifier JW °J15 State Certificate or Registration No. eF(!O q Certificate of Competency No. Architect/Engineer's Name (if applicable) Phone # 4a,/00, $ Value of Work For this Permit Type of Work: ['Addition fAlteratien . , Repair/Replace. __ 0 Demolition De e scribe Work: c w dra;�rri I Submittal Fee $ Permit Fee $ Notary $°- -- Training/Education Fee $ b , Gr”) Technology Fee $ 4 - 40 Scanning $ 3 00 Radon $ . Zoning Bond $ - 0 111x4 Code Enforcement $ Structural Plan Review. $ Total Fee Now Due $ ' v 4 (Continued on opposite side) Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: + , 756.8972 r � County Miami, -Dade Zip Z i p g Phone # W5 • /6 Square Footage Of Work: * * * * * * * * * * * ** ** * * * * * * * * * * * ** F lees * *** * ** *** * * * * *** * ** * * * * ** ** ** CCF $ I AD CO /CC Bonding Company's Name (if applicable) Bonding Company's Address City State Zip f � Mortgage Lender's Name (if applicable) 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 FL.F.CTRICAL 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 jp roved and a reinspection fee will be charged Chc 05/13/03 Owner or Agent _ �F The foregoing instrument acknowledged before me this 0/� day of %du' J , 20 U.a, by ihiy (k emitter who is personally known to me or who has produced VL 4 As `den on and who did take an oath. APPLICATION APPROVED BY: ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** , **. ; * ** Signature 14 Contractor The foregoing instrument was acknowledged before me thi9 day of 1 2005 by who is,persnnalLy known tome or who has produce d as identification e an oath. Engineer Zoning ** ******* **** ******* **** *** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** j Plans Examiner STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: [ ]New System [ ]Existing System [ ]Holding Tank [ X ]Repair [ ]Abandonment APPLICANT: Hugette Grounder PROPERTY STREET ADDRESS: 90 NW 110 St Miami FL 33168 LOT: 8 BLOCK: 219 PROPERTY ID #: 11 - 2136 003 - 0080 SYSTEM DESIGN AND SPECIFICATIONS OTHER REMARKS: [ ] Innovative Other ]Temporary [ NA ] AGENT: , A SUBDIVISION: Miami Shores [Section /Township /Range /Parcel No.] [OR TAX ID NUMBER] CENTRAX #: 13 - - 26042 DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 05 - 2611 - - 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. T [ 900 ]Gallons SEPTIC TANK MULTI - CHAMBERED /IN SERIES: [Y ] 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 [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 0 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [° ;STANDARD [ N ]FILLED [ N ]MOUND [ N ] I CONFIGURATION: [ N ]TRENCH y ]BED [ N N F LOCATION TO BENCHMARK: 12.9' NGVD FFE I ELEVATION OF PROPOSED SYSTEM SITE [ 1.9 ] [ FEET ] [ BELOW] BENCHMARK /REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 4.4 ] [ FEET ] [ below ]BENCHMARK /REFERENCE POINT L D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 42.0 ] INCHES 1. Install 900 gal. 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 300 sf of drainfield in the bed configuration. 4. Install 12" 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 dr.infie to be no less than 9.00' NGVD. 7. Bottom of drainfield a evatio' to be no less than 8.50' NGVD. SPECIFICATIONS BY: Andre, Paul TITLE: APPROVED BY: Andre, Pal.% TITLE: Professional Engin Dade CHD DATE ISSUED: 8/4/05 EXPIRATION DATE: 11/2/05 DH 4016, 03/97 (Obsoletes previous editions whic may not be used) (Stock Number: 5744 - 001 - 4016 -0) [ostds_cons_4016 - 1) . Page 1 of 2 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: [ ]New System [ ]Existing System [ [ X ]Repair [ ]Abandonment APPLICANT: Hugette Grounder SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ]Gallons SEPTIC TANK A [ 0 ]Gallons N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 I ELEVATION OF PROPOSED SYSTEM SITE [ E BOTTOM OF DRAINFIELD TO BE L D FILL REQUIRED:[ 0.0 ]INCHES OTHER REMARKS: APPROVED BY: Andre, Paul SPECIFICATIONS BY: Andre, Paul i. ]Holding Tank ]Temporary [ NA ] AGENT: , A PROPERTY STREET ADDRESS: 90 NW 110 St Miami FL 33168 LOT: 8 BLOCK: 219 SUBDIVISION: Miami Shores [Section /Township /Range /Parcel No.] PROPERTY ID #: 11 - 2136 003 - 0080 [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. D [ 300 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM R [ 0 ]SQUARE FEET SYSTEM A TYPE SYSTEM: [ ) ]STANDARD [ N ]FILLED I CONFIGURATION: [ N ]TRENCH [ y 'BED N F LOCATION TO BENCHMARK: 12.9' NGVD FFE ]GALLONS @ [ 0 ]DOSES PER 24 HRS # PUMPS[ 0 ] 1.9 ] [ FEET ] [ BELOW]BENCHMARK /REFERENCE POINT 4.4 ] [ FEET ] [ below] BENCHMARK /REFERENCE POINT EXCAVATION REQUIRED: [ 42.0 ] INCHES 1. Install 900 gal. 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 300 sf of drainfield in the bed configuration. 4. Install 12" 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 no less than 9.00' NGVD. 7. Bottom of drainfield elev tion to be no less than 8.50' NGVD. TITLE: DH 4016, 03/97 (Obsoletes previous editions which may not be used) (Stock Number: 5744 - 001 - 4016 -0) [ostds cons 4016 -1] CENTRAX #: 13 -SG -26042 DATE PAID: FEE PAID : $ RECEIPT . OSTDSNBR : 05 - 2611 - - [ ] Innovative Other MULTI - CHAMBERED /IN SERIES: [Y ] MULTI - CHAMBERED /IN SERIES: [Y ] [ N ]MOUND [ N ] [ N TITLE: Professional Engin Dade CHD DATE ISSUED: 8/4/05 EXPIRATION DATE: 11/2/05 Page 1 of 2 Scale: Each block represents 5 feet and 1 inch = 50 feet. ' - —'IL'12+ U• ■• f , •■r i - r _... L., I f NM Y 41, 711 t a • R`A's .r'"■ p t r i� d � O .. IIIIIMISSINI NS is III■ •• ■ is ma MI i - dui 1111111111011111111 MRS Illiri 4 II 1 + III MR rll { } �r ((VV � • MIS • ■■SIMMI • : • l •• t ¢ ! a l� _ i e SRO :num 1111111111111111111111 am dam SS 4.111 ° 'a SI _ �, ,., MSS F MO • NUM ■ n >�r11■■ , 1111 ■ it • � • •• ■� 'i■ ■ ■ um ■E•■•III•I ilEil■ ISMS • ■ .u.•.•�■• • i•••�• -; ■ ■ ,F. ■.•■ ••N■• II OR T , l • ■� •■• # II 11111111111111111111111111115111 • _ L- •� i> ■■ ■■• ■■ r ;- t • ■ /� ■It ■la ■• - T 1 "' II OSSORISSIUSIMIIIII 7 -' 1► . mu • 3ifw 11r IIUl r•s��N1t � r ■■III l t . ■• �- ill I� as. j NM ■tl�l1■■i• i � s *,`► II, MINISKIIIIIISIIIIIIII .,. .r_ .11;11111 IIMMII INSIIIMIN II 6 an • � • •- � •• � � A� • ■• ■• elm maim UMW as w4emay 4..� ; ' , ' z Notes: t � ., �: �� . .- 0 1 • . .... a " 5 � t ill � e STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION Permit Application Number PART II - SITE PLAN Site Plan submitted by: Plan Approved By DH 4015,10/96 (Replaces HRS-H Forth 4015 which may be (Stock Number: 6744-0024015-6) .d am Signature Not Approved Title Date s " 3' -05 County Health Department ALL CHANG UST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT Page 2 of 3 Scale: Each . block represents 5 feet and 1 inch = 50 f . _. rs 1 - -7- ,. ._ ,_ ' f - i s-t 4 ,I , -1-- 1 4 e - , ,.ww4 Vie= '"V— — "3""` .. 7- �""'� ---. w -.- r - -,.�i -.- k 1 „�, . .- 4-4-4-4- ,-. «'.,4_'..2__. , a ,L, . 1 � -t.,. a.,..._b _4:—: .a,, 1 , C i n VOMPI 14111410* • L ow FA 01 :iir all . sr s am t k' - I - r f i - --- - 1 . r 111111111111R a al alliaalianula maminamossaL, Immo q; i sm 11111.1111111111111.111111110111111M me? a 'ZA iu • iii III ONO Mau aliaalmaialiallaalE101 a anitilla Mai ' sin • 1 . 1 i 1 c , i . , ' 1 - u � a Nall it ' ' f 1 loin RN 1 t f 1 F T-f - AM! an al maim r t I V- .-, fag MB= MOM IMMINIIIIII a 44114440 Ma ORR n 4 t aanaluini mall - 1 1 1 I 1.111111111111 MIMI linim r - , gliiiiMialali inia ' , ,-, MA IllEIMINE 4.4•44144411111Nium no oat , n t 1 t rom Iii -- ' - i, t 1 1 , , i r -0 I , r -J- , • 111111111111111111111.1111401.1141.11 111111014111111111.11111MMINIME I ' p ili -1" ----4- '+- 11111111111111111114.114M1411 MB "; 1 , ; ; 11111114.11114111114MBEIMPIN , Ohl + 1 - ,- --v-- 1111111,1111111111.111MEMMIllillik , - If - 4- • 111 4 11111.141111411110 111111 -- , , 4 , I ,._, - 1 . .. , 44111411111111111114.1111 111 Ea imosiaminsaa i 11131_ IN-NealliilliganialWAMOniaiiiiiiiiIMMINUM, IMINSIMIMIHMOMMIlannallinnili 1111111.111111111.0111111.11111.11.11aginan mineammillUMII401141111111111141 figurionnomonno. 4 no oomounnomono •o assaansaanama .., , , .4-...- 4 i t am ii :IRAN -,- - aaamaanamanmiau I - 5=11 - 41marm 11411141141.11111114111111111111 EMU Nommousimnin _ 11111110. anima ___ I LC ' ' a. 144- , z 1 - i - , , 1Th t �� 4 ' Mfillitgetilb NUM ' 1 _ ' 7 r - I • 4 t k.. • MUM i - ii I + -I ' • 11111 i mu 011 A -- 11111111011 _4 ' ' 1- I I- . .. 1111 0,-- MN O M SIMS •• ••• • l ai l la I MI II III aim UUIU UIIUIIU MI I iliteemanidi beielirs 11111111111111111111 t--- al -i- nagin BEM t - i 111 111 .. 4 ... I a MHO 11411111111 - SIB! .....lent .,..... ,,- Notes: A I ....- , 40 , 14 1 - 4 0 t — i 1 A 5 e # . ,, Site Plan submitted by: Plan Approved By 0144015. 10198 (Replaces HRS-H Form 4015 which may be (Stock Number: 5744-002-40154) STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PE Permit Application Number PART II SITE PLAN ature ot Approved ALL CHANGEMUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT Title Date a" - 3-as County Health Department Page 2 of 3 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS AGENT: 4/0/6c Afide BLOCK: 2/9- SUBDIVISIONS L.l `` t �, �� PROPERTY ID #: [Section /Township /Range /Parcel No. or ax ID Number] TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, ORe`OTHER,U74 I_FIED PER$ON: ENGINEER'S MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: TOTAL ESTIMATED SEWAGE FLOW: AUTHORIZED SEWAGE FLOW: SZ UNOBSTRUCTED AREA AVAILABLE: 300 FERENCE POINT LOCATION: ELEVATION OF PROPOSED SYSTEM SITE IS SITE EVALUATED BY: DH 4015, 10/96 (Replaces HRS -H Form 4015 [Page 3) which may be used) (Stock Number. - ,5744 - 003 - 4015 -1) = = = = = == SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [10 10 YEAR FLOOD ELEVATION FOR SITE: FT MSL /NGVD SOIL PROFILE INFORMATION SITE 1 OBSERVED WATER TABLE: 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: ■=■= == = = = == — = = = = = = = =_= = _ YES [ ] NO NET USABLE AREA AVAILABLE: GALLONS PER DAY [RESIDENCES -TABLE 1 / O 2] GALLONS PER DAY [1500 GPD /ACRE OR CRE] SQFT UNOBSTRUCTED AREA REQUIRED: `,a SQFT ACRES THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES: SURFACE WATER: FT DITCHES /SWALES: 4,/#f FT NORMALLY WET? [ ] YES [JO WELLS• PUBLIC: FT LIMITED USE: IV,e4 FT PRIVATE: 44 4" FT NON-POTABLE: /4140-FT /�`'ii'`.0FT BUILDING FOUNDATIONS: FT PROPERTY LINES: 5 FT POTABLE WATER LINES: /" FT 10 YEAR FLOODING? [ ] YES [ BrNO SITE ELEVATION: /1 FT MSL/ SOIL PROFILE INFORMATION SITE 2 Munsell C•lor Texture Depth re ) - ifA - ? to to to ® to to to to to �. USDA -OIL SERIES: BE OW] EXISTING GRADE. TYPE: :ERCHED / APPARENT] INCHES [ ABOVE / ] EXISTING GRADE. MOTTLING: [ ] YES [ NO DEPTH: (4 INCHES � DEPTH OF EXCAVATION: „Re) INCHES '( " BED [ ] OTHER (SPECIFY) DATE: o Page 3 of 3 INSTRUCTIONS: PERMIT NUMBER: Permit tracking number by County Health Department. APPLICANT: Property owner's full name. AGENT: Property owner's legally authorized representative. LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot. PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section /township /range /parcel number). PROPERTY SIZE: Check if property 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 and exclusive of streams, lakes, normally wet drainage ditches, marshes, or other such bodies of water. SEWAGE FLOW: UNOBSTRUCTED AREA: MINIMUM SETBACKS: FLOOD INFORMATION: BENCHMARK SITE 1 [ +]SHOT H.I. H.I. [ - ] SHOT Record the estimated sewage flow for the establishment from Table 1 (residence) 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 10D -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 J 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 nonapplicable 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. Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation fdr site and actual site elevation. SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a 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 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 documents submitted. ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS: SITE 2 H.I. [ - ]SHOT SITE 3 H.I. [•]SHOT