PL-07-356Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Date: 05/03/2007
Inspector: Levrock, James
Owner: DOLL, ANN
Job Address: 100 95 Street NE
Miami Shores Village, FL
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
CL
Block:
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Drainfield
Phone Number
Parcel Number 1132060132860
Lot:
Phone: 305 -661 -6633
Building Department Comments
INSTALL NEW DRAINFIELD
MAY 0 4 2007
Inspectpr
Comments
Passed
Failed
Correction
Needed
Re- Inspection
Fee
($75)
No Additional Inspections can be scheduled until
re- inspection fee is paid .
Wednesday, May 2, 2007
Page 1 of 2
STATE O FLORIDA
DEPARTMENT OF HEALTI`i .
ON SITE SEWAGE TREATMEtsfr A
CONSTRUCTION INSPECTION $[I3 FINAL AI PROVAL
VD DISPOSAL SYSTEM
APPLICANT: c
E
PROPERTY ADDRESS:
LOT:
BLOCKa
RMIT
DATE PAID
FEE PAID:
RECEIPT 4t
-ERTY ID ft-
CHECKED' [X1 ITEMS ARE NOT IN . C0MPW ICE
TANK INSTALLATION n
(011 TANK SIZE-111
[02] - TANK;MATERIRL
[03] OUTLET DEVICE
] (04] MULTI- CHAAIIBERED 6/ N
1 [05] OUTLET FILTER
1 [06] LEGEND
] [07] WATERTIGHT
l [08] LEVEL
] [09] DEPTH TO LiD
AND IVIUST SE CORRECTED.
1291 PRIVATE WELLS
[30] PUBLIC WELLS
[31] IRRIGATION. WELLS
[32] POTABLSWATER'UNES
BUILDING _F FOUNDATION
Ll ,
PROPERTY LINES
[mil OTHER,
Fr
FT
FT
DRAINAELD INSTALLATION
0 AREA [11 (2J SQF T-
[11] DISTRIBUTION BOX HEA 3Ef
NUMBER OF 3[ AJNUNES
DRAINUNESEPARATION
DRAINIJIE SL.GPE
DEPTH OF COVER
ELEVATION [ 3OVE/B�
SYSTEM LOCATION
DOSING PUMPS-
AGGREGATE -
AGGREGATE_ EXCESSIVE FINE_ S
AGGREGATE DEPTH
PILL. / EXCAVATION- IATTERIAL
[221 FILL AMOUNT
(23], FILL TEXTURE
] [24] EXCAVATION DEP'II4
l [25] AREA REPLACED
] [26] REPLACEMENT MATERIAL
[351 -stopys
I391 ST ILI2A7ION
Ai�DIT 6NAL INFORMATION
[40] UNOBSTRUC7'71
[411 STORMWATEF
[42]
[43] MAII�iTENANCE AGREEMENT fi
[44] BUILDING AREA
451 LOCATION CONFORMS WITH fIE PLAN
[46] FlNAL SITE GRADING
[47] CONTRACTOR . '1-.
ABANDONMENT
(431 TANK PUMPED I
[50] TANK CRUSHED & FILLED I
EXPLANATION OF VIOLATIONSJ-REMARKS•
[:
CONSTRUCTION [APPROVEDSAPPROVED
�r.
FINAL SYSTEM.4APPROVE
ISAPPROVED] =.
CHD ,.DATE•
DH 4016 {Page 2), 10/97 (Previous Edltlotts May Be U
Stock Number: 9744-002-4016-4
Page 2 of 3
PT 1: Applicant
PT k inataUer/COntactor
PT 3: Building Department
PT4: Health Depariment
Miami Shores Village 09-1gfeu:-.
Building Department )64 "t •
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING ;
PERMIT APPLICATION '►'1
FBC 2004 FEB 2 3 2007
Permit Type: Plumbing BY'
YP
Owner's Name (Fee Simple Titleholder) A r,n Do 41
Permit No. 9101- 36e).
ster Permit No.
Phone #
Owner's Address 1 Cam; e Cl5 reel -
City R ShOreS State FL Zip 3313E
Tenant/Lessee Name v,--) Phone #
E -MAIL:
Job Address (where the work is being done) 0 we ct 5 SA-re . -
City Miami Shores Village County Miami -Dade Zip 331-33
FOLIO / PARCEL # 2..oG ) ° 2-8G0
Is Building Historically Designated YES NO t"
Ih�
Contractor's Company Name c a4"1 Gr P 1 h ne # .�� C
Contractor's Address 3--J9"0 - * ZC
City )e rep rreckr State It Zip 3-7-F 2 -
Qualifier Name ,sc; NO1 r @.O o Phone #
State Certificate or Registration No. W91 1 2 Certificate of Competency No.
E -MAIL:
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $ `2-e
Square / Linear Footage Of Work:
Type of Work: ['Addition ['Alteration ❑New la' Repair /Replace ❑ Demolition
Describe Work:
******** * * * * * ** * * * * ** * * * * * * * **x * * * * * * ** *Fees* gear********* xxxxxxxxxx * * *xxxxxxxxxxxxxxx ** **
Submittal Fee $
Notary $
Scanning $
Bond $
Permit Fee $
176-
Training /Education Fee $
Radon $
CCF $ . I - CO /CC
DPBR $
Technology Fee $ 4,1a7
Zoning $
Code Enforcement $ Double Fee $
Structural Review. $ Total Fee Now Due $ `-tl
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: 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 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 $2500, the applicant must
promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site
for the first inspection w 'c occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will `►t be a1 p ov' d and a r'nspection fee will be charged.
4 Signature
Signature
wry
Owner or gent Contractor
The foregoing instrument was acknowledged before me this 21 The foregoing instrument was acknowledged before me this
day of , 200/, by Pc 11 , day of 23 , 2001 , by —1-42v'$SG WIcYvvc.ho,
who is personally known to me or who has produced who is personally known to me or who has produced
As identi i ' � .. ► e an oath. V c"-Cuers Citevetas identification and who did take an oath.
NOTARY P
Sign:
Print:
°v®b TERESA J. SOLOMON
M 0 MY COMMISSION # 'JU 250437
top" E ,`l: ES. Septemba
.c' ARy ,, otoy,Discount Assoc. Co.
My Commission Expires:
My Commission Expires:
********* Yxa:***wwxxww********xx' ' *** ***** *****,tde********aYsYdc****** ** ****,a**************** ****x
die
// #�
p/
APPLICATION APPROVED BY:
(Revised 02/08/06)
oP —25.7"—‘17 Plans Examiner
Engineer
Zoning
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CENTRAX #: 13 -SG -32011
DATE PAID:
FEE PAID : $
RECEIPT
OSTDSNBR : 07 -00555 -R
CONSTRUCTION PERMIT FOR:
[ ]New System [ ]Existing System [ ]Holding Tank [ ] Innovative Other
[ X ]Repair [ ]Abandonment [ ]Temporary [ NA ]
APPLICANT: Doll, Ann AGENT: SA0021074, Solomon Teresa
PROPERTY STREET ADDRESS: 100 NE 95 St Miami Shores FL 33138
LOT: 13 BLOCK: 21
SUBDIVISION: Miami Shores Sec 1 A
[Section /Township /Range /Parcel No.]
[OR TAX ID NUMBER]
PROPERTY ID #: 11- 3206 - 013 -2860
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.
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
MULTI - CHAMBERED /IN SERIES: [Y ]
MULTI- CHAMBERED /IN SERIES: [Y ]
]GALLONS @ [ 0 ]DOSES PER 24 HRS # PUMPS[ 0 ]
D [ 300 ]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: FFE: 12.6' NGVD
[ N ]MOUND [ N ]
[ N ]
I ELEVATION OF PROPOSED SYSTEM SITE [
E BOTTOM OF DRAINFIELD TO BE
L
31.2 ] [ INCHES ] [ BELOW]BENCHMARK /REFERENCE POINT
61.2 ] [ INCHES ] [ BELOW]BENCHMARK /REFERENCE POINT
D FILL REQUIRED: [ 0.0 ]INCHES EXCAVATION REQUIRED: [ 30.0 ] INCHES
OTHER REMARKS:
1.- Install 300 sf of drainfield in bed configuration.
2.- Perimeter of excavation area shall be at least 2 ft. wider and longer than the proposed
absorption bed.
3.- Existing 900 gal. septic tank, certified by "Statewide Septic Connections, Inc." to
remain.
4.- Invert elevation of drainfield to be no less than 8.00' NGVD.
5.- Bottom of drainfield elevation to be no less than 7.50' NGVD.
* * ** *THIS PERMIT IS NOT FOR ADDITION(s) * * * **
SPECIFICATIONS BY:EDWARDS, ASTRID
TITLE: - :42 6,it
((11�
APPROVED BY: Edwards, Astrid - TITLE: Dade CHD
DATE ISSUED: 2/22/07
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744- 001 - 4016 -0) [ostds_cons_4016 -1]
EXPIRATION DATE: 5/23/07
Page 1 of 2
APPL
Scale: Each block represe
STATE OF FLORIDA
DEPARTMENT OF HEALTH
CATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT 1—
t, A 5-457?
(
Permit Application Number s
PART II SITE PLAN
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Site Plan submitted by:
Plan Approved V
By dieJ c,__
Signature
Not Approved
Ph, bt
TRIO
Date Id 7-7101
County Health Department
ALL COANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015. 10196 (Replaces HRS+I Form 4015 %Mich may be used)
(Sala Number 5744-002-40154
Page 2 of 3