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PL-09-2029Minimum n Wend _: sums, 14 Appileabko (Front : ; 127 or Calculations): L. Inspection Number: INSP - 131218 Scheduled Inspection Date: June 09, 2010 Inspector: Hernandez, Rafael Owner: RANDLE, JULIA Job Address: 285 NE 103 Street Miami Shores, FL Project: <NONE> Contractor: SEPTIC MEDIC Building Department Comments Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments HRS APPROVAL IN FILE June 08, 2010 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 Number: PL -12 -09 -2029 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1121360130440 Phone: (954)963 -6789 Page 2 of 26 E LI co ] O)5 _p£J A Goa ii um TA [01] [02] [03] [ [05] [06] [07] [08] [09] TANK SIZE [1] 6 0 [2] TANK MATERIAL 6� OUTLET DEVICE -. MULTI - CHAMBERED (1J N ] OUTLET FILTER '- - --- L. LEGEND 7o — /Y.3 — e, c WATERTIGHT �---� LEVEL -R-- -• DEPTH TO LID > DRAINFIELD INSTALLATIIO � ) [10] AREA [1] 11 SQFT [11] DISTRIBUTION BOX HEADER [12] NUMBER OF DRAINLINES [13] DRAINLINE SEPARATION .3( ' [14] DRAINLINE SLOPE [15] DEPTH OF COVER / ?� [16] ELEVATION [ABOVE/ EQW] - BM [17] SYSTEM LOCATION [18] DOSING PUMPS [19] AGGREGATE SIZE [20] AGGREGATE EXCESSIVE FINES [21] AGGREGATE DEPTH. FILL / EXCAVATION MATERIAL [22] FILL AMOUNT [23] FILL TEXTURE [24] EXCAVATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL EXPLANATION OF VIOLATIONS / REMARKS: CONSTRUCTION /DISAPPROVED] y' FINAL SYSTEM [APPROVED/DISAPPROVED]: DH 4016 (Page 2), 10/97 (Previous Editions May Be Used) Stock Number: 5744. 002 - 4016 -4 c r' 09 7 NO PAID' AID' IPT #• ID #:1: BE CORRECTED. WATER FT FT [29] PRIVATE WELLS FT [30] PUBLIC WELLS FT [31] IRRIGATION WELLS FT [32] POTABLE WATER LINES S' a. = FT -- [33] BUILDING FOUNDATION >' * ' FT [34] PROPERTY LINES 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 SITE PLAN [46] FINAL SITE GRADING [47] CONTRACTOR [48] OTHER ABANDONMENT [49] TANK PUMPED [50] TANK CRUSHED & FILLED - CHD DATE:' PT 1: Applicant PT 2: Installer /Conp8091. PT 3: BU CHD DATE:' -Z P 6 Paget of 1 C# 0 113 1,,`0 iltroblEfi Q I is 1 l 1 1 TANK [ [02] [031 [04] (05) [06] [07] [ [09] NS -- ; TANK SIZE [1] TANK MATERIAL OUTLET DEVICE MULTI - CHAMBER OUTLET FILTER LEGEND WATERTIGHT LEVEL DEPTH TO LID DRAINFIELD INSTALLATI [10] AREA [1] [11] DISTRIBUTION [12] NUMBER OF DR [13] DRAINLINE SEP [14] [15] [16] (171 N [2] SOFT X HEADER INLINES RATION DRAINLINE SLOPE DEPTH OF COVER ELEVATION [ABOVE/BELOW] BM SYSTEM LOCATION [18] DOSING PUMPS [19] AGGREGATE SIZE [20] AGGREGATE EXCESSIVE FINES [21] AGGREGATE DEPTH FILL / EXCAVATION MATERIAL [22] FILL AMOUNT [23] FILL TEXTURE [24] EXCAVATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL a EXPLANATION OF VIOLATIOKIS / REMARKS: CONSTRUCTIQN [APPROVED/DISAPPROVED]: y FINAL SYSTEIV4APPROVED/DISAPPROVED] DH 4016 (Page 2), 10/97 (Previous Editions May Be Used) Stock Number. 5744 - 002 - 4016 -4 D NOT [27] SURFACE WATER FT ] [28] DITCHES FT ] [29] PRIVATE WELLS FP ] [30] PUBLIC WELLS FT ] [31] IRRIGATION WELLS FT ] [32] POTABLE WATER LINES FT ] [33] BUILDING FOUNDATIONi FT [34] PROPERTY LINES FT J [35) OTHER FT FILLED / MOUND SYSTEM [36] DRAINFIELD COVER [37] SHOULDERS [38] SLOPES [39] STABILIZATION ABANDONMENT 1 [49] TANK PUMPED _./ i ] [50] TANK CRUSHED & FILLED AID D• T #• CORRECTED. [ ADDITIONAL INFORMATION ,,' [40] UNOBSTRUCTED AREA [41] STORMWATER RUNbFF [42] ALARMS [43] MAINTENANCE AGREEMENT [44] BUILDING AREA [45] LOCATION CONFORMS WITH SITE PLAN [46] FINAL SITE GRADING [47] CONTRACTOR ' -'• > ......- : a' [48] OTHER CHD DATE PT 1: Applicant PT 2: Installer /Contractor PT 3: Builthng Department PT 4: Health Department CHD DATE' iter- Page 2 of 3 285 103 Street Miami Shores, FL 1121360130440 Block: Lot: JULIA RANDLE Owner Information Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138-0000 Phone: (305)795 -2204 Address ' PRO IED Expiration: 06/14/2010 Phone Cell JULIA RANDLE 285 NE 103 ST MIAMI SHORES FL 33138 -2430 Contractor(s) SEPTIC MEDIC Phone Cell Phone (954)963 -6789 Type of Work: PLUMBING Type of Piping: DRAINFIELD AND TANK Additional Info: Bond Retum : Classification: Residential Fees Due Bond Type - Owners Bond CCF Education Surcharge Permit Fee - Additions/Alterations Scanning Fee Technology Fee Amount $300.00 $2.40 $0.80 $350.00 $3.00 $3.20 Total: $659.40 Authorized Signature: Owner / Applicant / Contractor / Agent Building Department Copy Valuation: Total Sq Feet: Invoice # PL -12 -09 -36611 Check it 1226 Total Amt Paid Amt Due $ 659.40 $ 659.40 $ 0.00 Bond #: 1917 Date $ 4,000.00 0 For Inspections please call: (305)762 -4949 Available Inspections: Inspection Type: Final Landscaping Rough 1 • 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 responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL, PLUMBING, MECHANICAL WINDOWS, DOORS, ROOFING and SWIMMING POOL work. OWNERS 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. Futhermore, I authorize the above -named contractor to do the work stated. December 16, 2009 December 16, 2009 1 Structural Review. $ 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 BUILDING PERMIT APPLICATION Master Permit No. FBC 20 Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) Metr k V 4 , -4i•e Phone # 3 QS" - 7 5C/ Owner's Address Z.SS S. E t 0 3 t CityR OA ¢, ari Q V S State P1--- Zip 3 313 S Tenant/Lessee Name fJ/ / Phone # Email k \ s - cot.. C ov, Job Address (where the work is being done) ` - . & . Dye City Miami Shores Village County Miami -Dade FOLIO / PARCEL # Is Building Historically Designated YES NO K Contractor's Company Name e li 4 M + r� G Contractor's Addres 1 1( Y M ,S0 I- nn City 1" Wcu, © State r L Qualifier Name 1Jf3 it-e old T ic,0 State Certificate or Registration No. g A 17� pi, 6 Arch' ec ngineer's Name (if applicable) 0 ?7/ 'l Phone # Zip 33a2 7 , Phone # 9 c 6:3 6 I e� Certificate of Competency No. Contact Phone Ct -54 qb 6) 9 E -mail 4LA1sek ( SC Phone # Value of Work For this Permit $ 06 Square / Linear Footage Of Work: Type of Work: EAddition AIRIAlteration LJNev� '( Re Describe Work: 6 U?� t V cR.i‘Cli , Total Fee Now Permit No. 9l 0(1- a Zip air Flood Zone c s ii -- 9 C 3 a 6L .c it place 0-Demolition G SU ******** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** e *********** * * * * * * * * * * * * * * * * * * * * * * * * * * *i * ** Submittal Fee $ Permit Fee $ ! CCF $ 2..40 CO /CC $ Notary $ Training/Education Fee $ o. Y0 Technology Fee $ 31 P0 Scanning $ 3-00 Radon $ DPBR $ , ietirt Bond $ � • Double Fee $ Violation date: 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 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 COMMIENCEMENT 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 t&e notice of commencement and construction lien law brochure will be delivered to the person whose'properly is Abject to attachinent. 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. Owner or Agent e fore ing instrument was ac : u o ledged be s me thi The foreg day of , 20�, b e k _ , day of who is per onally known to a or who has produced �� ho is 1 ( C . 0 01' 1' 2l1 L e tification and who did take an oath. (Revised 07 /10 /07)(Revised 06/10/2009) Contractor as acknowledg- d before me thi 6 i me or who has produced cation and who did take an oath. r���Q I I d'� ?1 . _ �`�®'�, Sign: 4�1L ; r .Q; S 2� E, ry,' Print 3 gi'vo My Commission Expires: .w r. ! � ` •2, ' � 3 : mac. S ***** * * * ** * ** * * * * * * * * * * * ** * * * * * ** * 44* * * * * * ** * ** *** ****A y** * *** * * * * ** • Plans Examiner {{66 Zoning Clerk checked STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID • SYSTEM con RECEIPT # DOCUMENT #: PR792443 CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Julie Randle PROPERTY ADDRESS: 285 NE 103 St Miami, FL 33138 LOT: Na BLOCK: Na PROPERTY ID #: 11- 2136- 013 -0440 SUBDIVISION: Na 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 Septic CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ 1 D [ 225 ] SQUARE FEET Trench confiauration drainfi SYSIEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [X] TRENCH [ ] BED [ ] N F LOCATION OF BENCHMARK: top of next higher floor, 11.70' NGVD I L D 0 T H E R ELEVATION OF PROPOSED SYSTEM SITE BOTTOM OF DRAINFIELD TO BE FILL REQUIRED: [ 0.00] INCHES EXCAVATION *Invert elevation of drainfield to be no Tess than 9.03 ft. NGVD. *Bottom of drainfield elevation to be no less than 8.53.00 ft. NGV -The licensed contractor installing the system is responsible for in sec. 64E- 6.013(3)(f). F.A.C. THIS PERMIT IS NOT FOR " ADDITION(s) ". SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: Carlos M Icaza Carlos M Icaza 12/08/2009 TITLE: DH 4016, 10/97 (Previous Editions May Be Used) PERMIT # -SC- 1081289 APPLICATION # AP944428 DATE PAID: [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] [ 12.00 ] [I INCHES I/ FT ] [ ABOVE BELOW I BENCHMARK /REFERENCE POINT [ 38.00 ] [ I INCHES I/ FT ] [ ABOVE 4 BELOW lI BENCHMARK /REFERENCE POINT REQUIRED: [ 26.00] INCHES D. o tailing the minimum category of tank in accordance with TITLE: AP94l 42s SE8025 ')5 Dade CHD EXPIRATION DATE: 03/08/2010 Page 1 of 3 ®® PARTII- Scale: Each bloc. represents 5 feet and 1 inch = 50 feet, Notes: Site Plan submitted by: Plan Approved By STATE O= FLORIDA DEPARTME T OF HEALTH APPLICATION FOR ONSITE SEWAGE UIS `'OSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number ALL CHANGES MUST BE APPROVED B 2414015. 10/813 (Replaces HRS-H Rem 4015 which may be used) EMS• .O, .10. a ®. ITE PLAN Signature NotApprved Date • Y THE COUNTY HEALTH DEPARTMENT `title County Health Department 13wa.a 4o4 °A .v ?a ®Q' VIVIANA CUBILLOS BUILDING DEPARTMENT PERMIT CLERK MIAMI SHORES VILLAGE 10050 N.E. SECOND AVE. Phone: (305) 795 - 2204 MIAMI SHORES, FLORIDA 33138 -2382 Fax: (305) 756 - 8972 CubillosV@MiamiShoresVillage.com Ee [ r'QC1C. - ria p 0 r-ecu r c (0r cFO,con(w(>4 3C WY 7? Employer Information Employer Name SEPTIC MEDIC INC Address , 1831 N 50Th AVE !City HOLLYWOOD 'State — _ FL _ lip ' -- : JCoull'1ty jBroward Employer I ype i ... CoRpORATroN{ . ijCode NA1CS FROM : Andy Tolomeo Septic Medic Inc FAX NO. : 9549635883 Employer Detail Page Workers* Cornp Home About Us Assessment Rates BetaaSt Delivery Pry Centralized Performance System at 440 F Statutes contact Us Data Dory trzSbict Offices EDI Frequent Questions History Memoranda/Bulletins Pubbcations Related Links Rules & Forms safOy Statistics What's New FLORIDA \ DEPARTMENT OF FINANCIAL SERVICES Alex Sink Misr Financial OtliccrofFlorida FLOES HOME CONTACT US SEARCH SY SUOJECT HELP EN ESPANOL SEARCH FLOFS i } I& rL Kt 495 °OM 14C1 Employer Detail Page This Database was Last Updated: 12/9/2009 10:15:54 PM Return to Query Form Name mhtml :file: //C :\Documents and Se itings\Anth ,__, No Coverage History Exemption Listings Click Exemption Holder's Name for Details. ANDREW TOLOMEO No Owner Election of Coverage Listings No Additional Locations Employer Name History • E mployer Name Name Type Change Date _.. I Legal . Current 4 Dec. 10 2009 11:37PM P2 Page 1 of 1 Return to Query Form DIVISION OF WORKERS' COMPENSATION (800) 742 -2214 cr (850) 413 - 1601 Florida Division of Workers' Compensation • 200 East Gaines Street - Tallahassee, Florida 323994228 • • Legal Notices Under Florida law, e-mail addresses are public records. If you do not want your e address released in response to a public records request, do not send electronic mall to this entity. instead, contact this office by phone or in writing. a t , FROM : Andy Tolomeo Septic Medic Inc FAX NO : 9549635883 •J ° «I1JL1lJl1 likaal L '—age - — —. FLDFS HOME CONTACT US Workers' Comp Home About Us Assessment Rates fl Delivery Process Centralized Performance System Ch. 440 FL Statutes Contact Us Databases Directory District Offices EDl Frequent Questions f -istory Memoranda/Sul Publications Related Links Rules & Forms Safely Statistics What's New Mr naaavmn IAA FLORIDA � OFD A Flt lR A CL AI SHIN/ICES SEARCH 8V SUBJECT HELP EN ESPA4OL MEP Chi¢f F'inlnriai Officer Alf F Sink Dec. 10 2009 11:37PM P3 Page 1 of 1 • SEARCH FLr9F$ IJ Exemption Detail Page This Database was Last Updated: 12/9/2009 10:15 :54 PM Return to Form Exemption Details Name — r� 1 Date Effective Date * Termination i Exemption • Employer i -Fide L�R Y Type ! Name ANDREW ! Termination may be through the revocation — .—. -i __ • TOLOMEO � �PR ' X 98 current � Non i SEPTIC ; L ; Construction MEDIC _ '` cation of the exemption INC_ exempfion. or invalidation a exemption_ albs • _ by failure to re -issue the e�cempbor,- 1 Return to Query Farm DIVISION OF WORKERS' COMPENSATION (800) 742 -2214 or (850) 413 -1601 Florida Division of Workers' Compensation - 2AA t Gaines strawt - Florida Building Code Edition 2002 High Velocity Hurricane Zone Uniform Permit Application Form. Section E (Tile Calculations) For Moment based tile systems, choose either Method 1 or 2. Compared the values for M with the values from M If the Mr values are greater than or equal to the Mr values, for each area of the roof, then the tile attachment method is acceptable. Method 1 "Moment Based Tile Calculatio s Per RAS 127" (PI: :z X ff 9 la ,..3 ) - Mg: 3 .. = Dirt (e). NOA M (P ' � � x �•05 Mg: Sh . = M.: NOA M. «, S Method 2 "Simplified Tile Calculation Per Table Below" Required Moment of Resistance (M From Table Below 3 a.a NOA Mr M Required Moment Resistance* 30' 40' Mean Roof Height -� Roof Slope 4, 15' 20' 25' 212 34.4 32.2 "12 4:12 5:12 30.4 6:12 712 28.4 26.4 24.4 36.5 34.4 32.2 30.1 25.9 38.2 36.0 33.8 31.6 28.0 29.4 27.1 39.7 37.4 35.1 32.8 30.5 28.2 42.2 39.8 37.3 34.9 32.4 30.0 *Must be used in conjunction with a list of moment based tile systems endorsed by the Broward County Board of Rules and Appeals. For Uplift based tile systems use Method 3. Compared the values for F' with the values for F,. If the F' values are greater than or equal to .the F values, for each area of the roof, then the tile attachment method is acceptable. Method 3 "Uplift Based Tile Calculations Per RAS 127" (PI : x l: = x w: = ) - W: x cos 0 = F „: (P2 : z l: = x w: = ) - W: x cos 6.• = (P : x l: = x w: = ) - W: x cos 8.• = Fes. Design Pressure Mean Roof Height Roof Slope Aerodynamic Multiplier Restoring Moment due to Gravity Attachment Resistance Required Moment Resistance Minimum Attachment Resistance Required Uplift Resistance Average Tile Weight Tile Dimensions 14.4, M F' F, w 1= length w= width Description Form AB -326 ( Page 5 of 5) New 1/16/02 Where to Obtain Information Symbol Where to find RAS 127 Table 1 or by an engineering analysis prepared by PE based on ASCE 7 Job Site Job Site NOA NOA NOA Calculated NOA Calculated NOA NOA NOA F' NOA F' NOA F' cial at the time of permit application. APPLICANT: . ; AGENT: PROPERTY ADDRESS: LOT: [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] STATE OF FLORIDA PERMIT NO DEPARTMENT OF HEALTH DATE PAID ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID CONSTRUCTION INSPECTION AND FINAL APPROVAL RECEIPT #. BLOCK:- FILL / EXCAVATION MATERIAL [22] FILL AMOUNT , [23] FILL TEXTURE [24] EXCAVATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL EXPLANATION OF VIOLATIONS / REMARKS: [ 1 1 ] SUBDIVISION: PROPERTY ID #. 1 - • •' • -* • CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION [01] TANK SIZE [1]/ 12] [02] TANK MATERIAL [03] OUTLET DEVICE' [04] 11/LULTI:CHAMBEFIE - [05] OUTLET FILTER [06] LEGEND 7 • [07] WATERTIGHT [08] LEVEL [09] . "__DEP - TWTO - 110 - •:' DRAINFIELD INSTALLATION AREA [1]- SOFT DISTRIBUTION BOX HEADER .s. NUMBEFil6F13RAINCINE,_ DRAINLINE SEPARATION DRAINLINE SLOPE DEPTEIV COVER 9 ELEVATION[ABOVE/BELOWIltlyi [ SYSTEM1*ATION 1 1 DOSING PUMPS AGGREGAT&-SIZE.. s' : AGGREGATE EXCESSIVE AGGREGATE DEPTH [40] [41] [42] [43] [44] [45] [ [ [ [ ] [48] [ SETBACKS [27] SURFACE WATER FT [28] DITCHES FT [29] PRIVATE WELLS FT [30] PUBLIC WELLS FT [31] IRRIGATION WELLS FT [32] POTABLE WATER LINES FT [33] BUILDING FOUNDATION - FT [34] PROPERTY LINES FT [35] OTHER FT FILLED / MOUND SYSTEM [36] DRANFIELD COVER [37] SHOULDERS [38] SLOPES [39] STABILIZATION ADDITIONAL INFORMATION UNOBSTRUCTED AREA STORMWATER RUNOFF ALARMS MAINTENANCE AGREEMENT BUILDING AREA LOCATION CONFORMS WITH SITE PLAN FINAL SITE GRADING CONTRACTOR OTHER ABANDONMENT [49] TANK PUMPED [50] TANK CRUSHED & FILLED / CONSTRUCTION [APPROVED/DISAPPROVED?. DH 4016 (Page 2), 10/97 (Previous Editions May Be Used) Stock Number. 5744-002-4016-4 FINAL SYSTEM [APPROVED/DISAPPROVED]: CHD DATE PT 1: Applicant PT 2: Installer/Contractor PT 3: Building Department PT 4: Health Department CHD DATE • - Page 2 of 3