PL-09-1910Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 129615
Scheduled Inspection Date: November 30, 2009
Inspector: Levrock, James
Owner: GREEN, GIL & DEANNA
Job Address: 113 NE 101 Street
Miami Shores, FL 33138-
Project:
Permit Number: PL -11 -09 -1910
<NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060131910
Phone: 305 -661 -6633
Building Department Comments
REPLACE BROKEN SEPTIC TANK AND DRAINFIELD.
ABANDON SEPTIC TANK
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
o iInents
L IN FILE. OK
November 25, 2009
For Inspections please call: (305)762 -4949
Page 8 of 12
v W • 4K
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Mail 196\e d1
BUILDING
PERMIT APPLICATION Master Permit No.
FBC 20
Permit Type: PLUMBING
Owner's Name (Fee Sim le Titleholder) Phone #
Owner's Address l "4-- x4-1 �, 1 1 3 m.- .- t D
City L AinA. ( State t Zip . V
Miami Shores Village \ p$
Building Department Vs Nov ' 7 2009
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972 �pOe m__—
INSPECTION'S PHONE NUMBER: (305) 762.4949
Permit No. l 01� C i / C)
�i
Tenant/Lessee Name Phone #
Email
Job Address (where the work is being done) 11-5 NI E ) 01 ST
City Miami Shores Village County Miami -Dade Zip 3 3;1 3E
FOLIO / PARCEL # I - y i j 6 ` o (3 °-t °I t
Is Building Historically Designated YES NO Flood Zone
Contractor's Company Name S `el eu) ■ cze, S C ` Phone # 31966/- 6I� "3
Contractor's Address '3S� 0 ,5 0 S - "7 0- 26
City MI Ca irr1C V State FL Zip -z-3
Qualifier Name ' ± -a E c; (S-01.9 en- , Phone #
State Certificate or Registration No. S IL'M G' 0( n t 26 'Z Certificate of Competency No.
Contact Phone E -mail
Architect/Engineer's Name (if applicable)
Value of Work For this Permit $
Type of Work: ❑Addition
Describe Work:
Phone #
9
quare)/ Linear Footage Of Work:
I cu
❑Alteration New .�� Repair/Replace ❑ Demolition
R-ep Axcin Rie(d > A[ e icr-,
c r
******** * * * * ** * * * ** * * ** * * * *** * * * *** * * ** Fees *** ** * * ** * **** ** ** ** * * * * * * ** ** ** * * * ** * * * * **
Submittal Fee $ Permit Fee $
-on CCF $
Notary $ Training/Education Fee $
Scanning $5' � Radon $
Double Fee $
Structural Review. $ Total Fee Now Due $ 6� e) •�" 0
See Reverse side -+
DPBR $
Violation date:
CO /CC $
Technology Fee $�,
Bond $3C0 I et a0
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 MR 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 L- (1 Signature
11 Owner or Agent Contractor
The forego ;.s g instrument was acknowledged before me this /.)-- The foregoing instrument was acknowledged before me this
day of ? - , 20 efi, by , day of , 20 _, by
who is persona y known to me; or who has produced 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: NOTARY PUBLIC:
rIpvuuurf►` .euaaeu ■OuIuu COI ®OuIu usu
My Commission E4ores: I -± NE DAKOTA
`�t„uw,•• • • mm# DD0?23184
` Y
Ires 10/8/2011
* * * * * * * * * ** - -' ** :mac. *..� s,. .,., : � �19.4tl44110k,S*** *9r�Y�Y***
'Xlir.il.frx: �
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Sign:
Print:
My Commission Expires:
**************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
®�
Pla l 'her Zoning
Engineer Clerk checked
(Revised 07 /10 /07)(Revised 06/10/2009)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Andrea Singer
PERMIT #:13 -SC- 1008605
APPLICATION #: AP941770
DATE PAID
FEE PAID:
RECEIPT #:
DOCUMENT 8: PR789961
PROPERTY ADDRESS: 113 NE 101 St Miami, FL 33138
LOT: 15-17
BLOCK: 14
PROPERTY ID #: 11- 3206 - 013 -1910
SUBDIVISION:
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
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
MATERIAL FACTS,
TO MODIFY THE
NULL AND VOID.
OTHER FEDERAL,
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T[
A [
N [
K [
D
R
A
I
N
F
I
E
L
D
O
T
H
E
R
900 ] GALLONS / GPD
] GALLONS / GPD
] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY [
Septic
[ 150 ] SQUARE FEET
[ ] SQUARE FEET
TYPE SYSTEM: [R] STANDARD
CONFIGURATION: [X] TRENCH
LOCATION OF BENCHMARK:
CAPACITY
CAPACITY
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
mums 8[ ]DOSES PER 24 HAS #Pampa [ ]
SYSTEM
SYSTEM
[ ] FILLED [ ] MOUND [ 1.
[]BED [1
F.F.E.: 12.9' NGVD
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED:
[ 30.00 l 11-1 FT ] [ ABOVE /LBELOW U BENC /REFERENCE POINT
[ 78.00 ] INCHES FT ] [ABOVE _ =LOW BENCHMARK /REFERENCE POINT
[ 0.00 ] INCHES EXCAVATION REQUIRED: [ 48.00 ] INCHES
THIS PERMIT IS FOR THE SYSTEM IN THE REAR: 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 150 sf of drainfield in trench configuration 4- Perimeter of excavation area
shall be at least 2 ft wider and longer than the proposed absorption trench. 5- Invert - > d fieo less than
6.90' NGVD. 6. Bottom of drainfield elevation to be no less than 6.40' NGVD. 7. Existi y ` Ei e t east
of property to remain.. yliftlitDADE COUNTY HEALTH DEPARTMENT
THIS PERMIT IS NOT FOR ADDJJION(s).
SPECIFICATIONS BY: OSPINA
APPROVED BY:
o N °spina G
DATE ISSUED: 11/09/2009
TITLE: - Legacy
Dade CHD
EXPIRATION DATE: 02/072010
DH 4016, 10/97 (Previous Editions May Be Used) Page 1 of 3
v 1.1.4
AP941770 6E800684
MOM. 1■14$
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
. A 4
Permit Application Number
Scale; Each block represents 5 feet and 1
7117-777,
PART II - SITE PLAN
inch = 50 feet.
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Site Plan submitted by:
Plan Approved
By
Not Approvel
Date
- County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
OH 465. 10196 (Replaces HEIS-H Form 4018 which may be used)
(Stock Number: 5714-002-40154)
Page 2 of
PERMIT #: 13-SC-1008610
APPLICATION #: AP941774
STATE OF FLORIDA
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID;
SYSTEM
RECEIPT #•
DOCUMENT #: PR789916
CONSTRUCTION PERMIT FOR: OSTDS Abandonment
APPLICANT: Andrea Singer
PROPERTY ADDRESS: 113 NE 101 St
LOT: 15 -17
Miami, FL 33138
BLOCK: 14 SUBDIVISION:
PROPERTY ID #: 11- 3206 - 013 -1910
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
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 [ ] GALLONS / GPD CAPACITY
A [ ] GALLONS / GPD CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS 8[ ]DOSES PER 24 HRS #Pumps [
D
R
A
I
N
F
I
E
L
D
0
T
H
E
R
[ ] SQUARE FEET SYSTEM
[ ] SQUARE FEET SYSTEM
TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [ ] TRENCH [ ] BED [ ]
LOCATION OF BENCHMARK:
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED: [ 0.00] INCHES
/ ][ABOVE/BELOW P3ENCEIMARK/REFERENCE POINT
/ ][ABOVE/ BELOW] BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ ] INCHES
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 / PEDRO N OSPINA TITLE: - Legacy
APPROVED BY: � TITLE: // Dade CHD
Pedro N Ospina
DATE ISSUED: 11/09/2009 EXPIRATION DATE: 02/07/2010
DH 4016, 10/97 (Previous Editions May Be Used) Page 1 of 3
v 1.1.4
AP941774 SE -1
APPLIC
STATE OF FLORIDA
DEPARTMENT OF HEALTH
TION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN
Scale: Each block represents 5 feet and 1 inch = 50 feet.
II al 4
WOW IN
M:� - _ or
moo
IN MN
m•
NMI
i111NU
auRIMOR
as IMIMUMM
Notes:
Site Plan submitted by:
Plan Approved -
By
Signature
Not Approved
ALL CliiANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Title
Date
County Health Department
D144016. 10195 (Replaces HRS-H Form 4015 Which may be used)
(Stock Number: 6744- 002 - 40164)
Page 2 of
9100k- lot‘e
•APPLICA
AGENT:_
PROPER`
LOT:
CHECKED
TANK INSTALLATION
[01] TANK SIZE [1] [2]
[02] TANK MATERIAL
[03] OUTLET DEVICE -
[04] MULTI - CHAMBERED [Y / N ]
[05] OUTLET FILTER
[06] LEGEND
[07] WATERTIGHT
[08] LEVEL
[09] DEPTH TO LID
DRAINFIELD INSTALLATION
[10] AREA [1] [2] SQFT
[11] DISTRIBUTION BOX HEADER
[12] NUMBER OF DRAINLINES
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER
[14 ELEVATION [ABOVE/BELOW] 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
EXPLANA , CYPECITOLVIKS:
[ i NOV 2 5 2009 j
[ 1
[
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] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER OUNOFF
[42] ALARMS
[43] MAINTENANCEAGREEMENT
[44] BUILDING AREA
[45]
(46]
[47]
[48]
LOCATION CONFORMS WITH SITE PLAN
FINAL SITE GRADING
CONTRACTOR
OTHER
ABANDONMENT
[49] TANK PUMPED /
[50] TANK CRUSHED & FILLED
mmm.®.®.o•o
CONSTRUCTION, [APPROVIBID/DISAPPROVEDJ
FINAL SYSTEM [APPROVED7DISAPPROVED]:
DH 4016 (Page 2), 10/97 (Previous Editions May Be Used)
Stock Number: 5744 - 002 - 4016 -4
CHD DATE-
h -4 CHD DATE.t
PT 1: Applicant
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
Page 2 of 3
Rmdd Aga
TANK INSTALLATION
[01] TANK SIZE [1]
[02] TANK MATERIAL
[03] OUTLET DEVICE
[04] MULTI - CHAMBERED [Y % N ]
[05] OUTLET FILTER
[06] LEGEND s
[07] WATERTIGHT
[08] LEVEL
[09] DEPTH.TO LID `-
[2]
DRAINFIELD INSTALLATION
[10]
[91]
[12]
[13]
[14]
[15]
[16]
(17]
[18]
[19]
[20]
[21]
AREA [1] :' ,s: [2] -.SQFT
DISTRIBUTION BOX HEADER
NUMBER OF DRAINLINES
DRAINLINE SEPARATION
DRAINLINE SLOPE
DEPTH OF COVER
ELEVATION [ABOVE/BELOW] BM
SYSTEM LOCATION
DOSING PUMPS
AGGREGATE SIZE
AGGREGATE EXCESSIVE FINES
AGGREGATE DEPTH
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
0 NOV 2 5 2009
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] 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 _/
I-
CONSTRUCTION -[APPROVED /DISAPPROVED]
FINAL SYSTEM- [APPROVED/DISAPPROVED]
OH 4016 (Page 2), 10/97 (Previous Editions May Be Used)
Stock Number: 5744- 002 - 4016 -4
CHD DATE-
CHD DATE.
PT 1: Applicant
PT 2: Installer /Contractor
PT 3: Building Department
PT 4: Health Department
Page 2 of 3
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