PL-11-894Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 159868 Permit Number: PL -5 -11 -894
Scheduled Inspection Date: June 17, 2011
Inspector: Hernandez, Rafael
Owner: PATNIK, JOHN
Job Address: 100 NW 100 Terrace
Miami Shores, FL
Project: <NONE>
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number (305)757 -5639
Parcel Number 1131010220290
Contractor: STATEWIDE SEPTIC CONNECTIONS Phone: (954)963 -0082
Building Department Comments
REPLACE DRAINFIELD
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
HRS APPROVAL
June 16, 2011
For Inspections please call: (305)762 -4949
Page 6 of 12
sle>c 1 I
LAI(
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
FBC 20
Permit Type: PLUMBING
OWNER: Name (Fee Simple Titleholder): 50 kr1 Pc/ "Fri K
Address:] 00 N..xi 00 Tee
City: (`■ .01 0 teS
State: FL
Permit No. PL-S-II -894
Master Permit No.
Phone#:
Zip: 33 Y ��
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: O 0 N1. J t -rte
City: Miami Shores County: Miami Dade Zip: 3-31C O
Folio/Parcel #:
Il -5I01- 022 --Q2 o
Is the Building Historically Designated: Yes NO L® Flood Zone:
-F 'de �' 1 fi'C 3' 66I --6633
CONTRACTOR: Company Name: �'q �L� r �r G �.I't M.i� Phone #:
Address: ' 0 S St
City: 1°A.16+-0.. vy,,,09,- State: fL Zip: i3O 2-3
Qualifier Name: Teres I ® 40,-. Phone #:
State Certification or Registration #: &NOR'-) t Z Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 2--(5 Square/Linear Footage of Work: ISO 0
Type of Work: Address ❑Alteration ❑New C ' epair/Replace ❑Demolition
�;
Description of Work: r,-
*************** * * * * **+x*** ***** **:u****** Fees*** :******x:***** : **** ** * *** *+x*x:**** ******* **
Submittal Fee $ Permit Fee $ /5-
CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $
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
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.
Owner or Agent
The foregoing instrument was acknowledged before me this y 16 The foregoi ,��
day of , 2(A , by , day of �.
who is personal known to me or who has produced who s p
Imossik Imm ® ria o 8 iiiiii an oath.
NOTARY PUBLI '70% Comm* ®®0733346
C moires 1108!2011
inoce Florida NAM •, kw
p... mmmmmaemmmeammmmmmmmmmmammmmmmmmmmnaes ®aa
Signature
Sign:
Print:
My Commission Expires:
Ste.
Contractor
nstrument wa ackno ledges befor
, 20 1 , by !
L '
o m s who has produced
as identification and who did take an oath.
My Commission Expires:
** * * * * * * * * **** * *** ** * ******* ** **; **********************:********************** * ** * ** * *** *** * **** ***** * ** ** ***
APPROVED BY
Plans Examiner Zoning
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
,NSITE SEWAGE TREATMENT-AND `OISPOSALSYSTEM
CONS.TRtUCTIO'N INSPECTION AND FINAL APPROVAL -
PERMIT NO [03 t
DATE PAID
A.. FEE PAID:
RECEIPT #:
PROPERTY
LOT:= 51
ROPPRT`( ID#;
CHECKED ' [X1 .11;EMS ARE iNOT IJU 'm J I LI�A1 aE
TTANK INSTALLATI.QN
(OM TAIif f [i ] [3]
[fl2{ fiANK MAT ERIAL' a •
{03] OUTLET DEV1OE
[04] MULTI CHAMBERED / "N
[05] OUT1_Et TILT .
[G6] LEGEND _
1071 WATERTIGHT .
[A5] ,LEVEL '
] , j09]
D1A1t�u150 INSTAL •
] {i ] ARIEA [i] ' SOFT
[ ] iii] DUSTf3+IB 1014 B X HEADER Irr
] 412] L kUy6$11E-R Q bRAMNLINES =
[ 1 {13] 1L E SEPARATION
[ i 11.41 RAU;_ m lE ]; $i &E :
rje—FMil 'OE COMER
[ [163 EVATIQ itI ®y 'BM '
iH „STrA 'UTE. OR RULE BIND MUST . SE CORRECTED:,
SETE. S
[ 1.-- [ 'SURFACE WATER _ FT
1 DITCHES FT
[ ] P13JVATE WE1 LS FT
[, ..1- '[3 ] p.VBLIC WELLS FT
[.. ] -[31] 1R+RIGATION W1 .LLS FT
[ 1 -[32] POTABI;;E WATER LINES + - FT
[- _ ] [3i,"'''''''''' ;tS tiki000 FC .NDAi p ®'' - FT .
[-- ]o [34] PROPERTY LINES FT
[ ], [5 OTHER' - FT
FILLED. ®FUND S`STEM
[ ]. [36] DRAINFIELD COVER
[ _ j, [37] SHOULDERS
[ ] [.39] . ::STABILIZATION
ADDITIONAL INFORMAT101
. {1-0] - UNOB'g,3744U pTEDrvtif'' ,�
[' ]p [41] STORMWATER RUNOFF
is
[ ] {42) ALMMS
[ ] [43] MAIMTENNCE;,A>=EENT . =
[ -• ] [44] BUILDING AREA
[45] «,LOCATtON,CON Q IJ7&WITH TE PLAN
[ ]
1'48]
[
]..1481
FINAL SITE GRAD NG
NTRAO1(Oa _
',OTHER'
1BANfi ONM'ENT
[4r TANK f?UfuIP "ED
[50]
-TANK= CRUSHED & FILLED l —.
tVbf$At?PROV1='_
nsn =b ,n uf.. :. \ •adiA�- ISf.... r....., a.�iti:..... i1:... fl YLi.. .V1
Page 2 of 3
DIVISION OF.
vironmenta! Health
epartnient flf Health
e County Health Department
OS`I'DS %Well Division
t 1�S05 SW •26 St: • Mtami, FL 33175
Address
Coi efts
Date (/7 /1/
OSTDS # 4
Signature
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: John Patrik
PERMIT #:13 -SC- 1350138
APPLICATION #: AP 1035861
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR844832
PROPERTY ADDRESS: 100 NW 100 Ter Miami, FL 33150
LOT: 6
BLOCK: 4 SUBDIVISION:
PROPERTY ID #: 11- 3101 -022 -0290
[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 [
A [
N [
K [
600 ] GALLONS / GPD Septic existing
0 ] GALLONS / GPD
0 ] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY
CAPACITY
CAPACITY
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 150 ] SQUARE FEET in trench configuration SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND
I CONFIGURATION: [x] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: FFE : 13.10' NGVD
I
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED:
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
[ 0.00 ] INCHES
[ 24.00 ] [I INCHES I FT ] [ ABOVE A BELOW b BENCHMARK /REFERENCE
[ 48.00 ] [I INCHES If FT ] [ ABOVE /) BELOW I] BENCHMARK /REFERENCE
EXCAVATION REQUIRED: [ 24.00] INCHES
POINT
POINT
- Install 150 sq ft drainfield in trench configuration.
- Elevation of bottom of drainfield to be no less than 9.10' NGVD.
- 600 g existing septic tank to remain.
- Not for additions
DH 4016, 08/09 (Obs
Incorporated: 64E-
Orville E
2
The contrami (IA ncsignee) is required to perform a
soil boring adjacent to the drainfield excavation at the
time of final inspection. Prior to Final Approval, the DOH
inspector shall witness the soil boring and compare the
results to the original site evaluation submitted. A
reinspectien fee will be assessed If the contractor is not
at the iobsite at the arranged time.
TITLE:
TLE: Engineer Specialist II
etes all previous editions which may not be used)
.003, FAC
v 1.1.4
AP1035861
Dade
EXPIRATION DATE: 08/11/2011
SE844143
CHD
Page 1 of 3
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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT.
• PART II - SITE PLAN-
Scale: Each block represents 5 feet and 1 inch = 50 feet.
Permit Application Number
• • , 5
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Site Plan submitted
PlariApproved
By
1/
.5/
Signature
Not Approved
Title
.rn
Dat0)-7 .'"°;11
County hpalth Department
ALL CHANGES iViUST BE APPROVED BY THE COUNTY HEALTHDEPARTMENT
OH 4015. 10/98 (Replaoes HRS41 Form 4015 which may be used)
(Stock Number: 57444302-40154)
Page 2 of '3