PL-11-317Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 163808 Permit Number: PL -2 -11 -317
Scheduled Inspection Date: August 26, 2011
Inspector: Hernandez, Rafael
Owner: WIESE, HEISE
Job Address: 149 NW 93 Street
Miami Shores, FL 33150-
Project: <NONE>
Contractor: NU BLACK SEPTIC & DRAINFIELD COMPANY
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1131010330850
Phone: (954)410 -2589
Building Department Comments
INSTALLATION OF 900 GAL SEPTIC TANK AND 300 SQ
FT OF DRAINFIELD IN TRENCH CONFIGURATION
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
CREATED AS REINSPECTION FOR INSP- 157001. CREATED AS
REINSPECTION FOR INSP- 156339.
August 25, 2011
For Inspections please call: (305)762 -4949
Page 9 of 9
'1
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' ?fly- �;� —vv1TH ATE OR RULE AND MUST 'BE CORRECTED.
--------------------------------------
TANK INSTALLATION -
[01] TANK SIZE [1)105C) } [2)
[02] TANK MATERIAL.'
[03] OUTLET DEVICE ¢ — °'4-
[04] MULTI - CHAMBERED t[-Y.,'/ N
[05] OUTLET FILTER r <_
[06) LEGEND ; I Ls. _r
[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 )2..
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER / ,�,•
[16] 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
SETBACKS
[ ] [27] SURFACE WATER FT
[ ] [28] DITCHES FT
[ ] [29] PRIVATE WELLS FT
[ ] [30] PUBLIC WELLS FT
[ ] [31] IRRIGATION WELLS FT
[ _-] [32] POTABLE WATER LINES YO FT
[ —1 [33] BUILDING FOUNDATION < FT
[ ✓]' [34) PROPERTY LINES /("1 FT
[ ] [35] OTHER FT
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATEF4 RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTOR tic / 4
[48] OTHER
ABANDONMENT
[49] TANK PUMPED
[50] TANK CRUSHED & FILLED / %
EXPLANATION OF VIOLATIONS / REMARKS: ';����
[ 1
[
[
[ 1
CONSTRUCTION [AP RP O DVE D)SAPPROVED]
ANAL SYSTE APPROVED /DISAPPROVED]:
DH 4016 (Page 2), 10/97 (Previous Editions May Be Used)
Stock Number: 5744- 002 - 4016 -4
CHD DATE*
CHD DATE—) `)
PT 1: Applicant
Page 2 of 3
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 Noll
yorroTqw31
EB 2, 4 2011
131; I
1151)
Master Permit No.
Permit Type: PLUMBING / r/ /� ¢�
OWNER: Name (Fee Simple Titleholder): e(1« W� S5 Phone#: X5 5' ` 23
Address: t t( G 0'v(A) .S+'
City:. (a,m '1-1 Ov-P 5
Tenant/Lessee Name:
State:, -
V. S e
Zip:
Phone#: 3z:137S-725 Litt
Email:
JOB ADDRESS: l .( �i�(l q 3 s+
City: Miami Shores County:
Folio/Parcel #: 1— �� o 1— o 33 o- 5 Q
Miami Dade
Zip:
Is the Building Historically Designated: Yes NO Flood Zone:
CONTRACTOR: Company Name: (et —b (of c is c- d Or r f1 e (d �vPhone#:
Address: 0-1 NI/v 'vim ►�1(e(e
City: b /°1 i& ! 9ij` I l� State:
Qualifier Name: V) O� V .,` V tii
State Certification or Registration #: 5'4 00 i 7 0
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Zip: 33 C oV-
Phone#: 615—c( . (NO o)j
Certificate of Competency #:
Value of Work for this Permit: $ Cif (50 0/ () G Square/Linear Footage of Work: 3 O O
Type of Work: ClAddress UAlteration t Tew C)epair/Replace ODemolition
Description of Work: t it Ot j 14f' td ¶ 2 (C TAINI ANQ C
**** *********** ***************** * * *** **F : x: x: x***:x*x:** ** ********* *** ** ****************
Submittal Fee $ Permit Fee $ ,6 0 CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ :4 ° u
; onding 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 FT FCTRICAL 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 conunencement 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 . t be approv( and a reinspection fee will be charged.
■
Signature 1 (0 `d Signature
Owner or Agent
The foregoing instrument was acknowled ed before me this The foreg
day of �� , 20 a, by 4e_1 l� e4a�, , day o
who is personally known to me or who has produced
As identification and who did take an oath.
who is
Contractor
ing instrument was ac ' edged forree1me thisa{4
,2011_, by;' 0 14 G ' `4
rsona/llykn wn to me or who has produ
LoJ as identification and who did take an oath.
OTARY PUBLIC: •
My Commission Expires:
N0.yil Y PUBLIC-8 ATE OF FLORIDA
David Nuby, Jr.
I ;;,_ Commission #DD723' ".1
,,,,..•'' Expires: OCT. 10 1
* * * ** * * * * * * * * * * * * * * * ** . NNW : ," - °- -' Q4** W******** * *** * * * * *** * * * * * * * * * *** * * **** **
Sign:
Print:
My Commission Expires:
9'
APPROVED BY
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
* * * * * * * * * * * * ** * * * **
Zoning
Clerk
02/24/2011 17:16 9545839802 JW INSURANCE PAGE 01/01
® DATE (h9NUDDIYY)
CERTIFICATE OF LIABILITY INSURANCE 02/24/11
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGL AFFORDED BY THE POLICIES BELOW.
NAIC #
PRODUCER JVd Insurance Services
100 North State Road 7, # 106
Margate, FL 33063
Phone (954)583-7213 Fax (954)583 -2045
INSURED Nu- Black Septic & Drainfield Company, Inc
401 SW 12th Avenue
Dania Beach, FL 33004
! INSURERS AFFORDING COVERAGE
INSURERA; Canal Indemnity_
. INSURER B:
j INSU)t��i�
-
INSURag G:
_ ._....... .. ,._ _...
INSURER E: _
-
COVERAGES INSURER F:
-
THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING •
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ -- .I
INSR Abb'L
INSR TYPE OF INSURANCE POLICY NUMBER PouoY EFFTIVE POLICY 17CPIRATION
.�13_. _.._.4 . ... _ . _ . • -- --•_ -° ....DATE LMMnyAfYY) DATE (MEdUDU/YYj - -..... LIMITS _
GENERAL LIABILITY EACH OCCURRENCE - 100,000
• -. COMMERCUIL GENERAL LIABILITY GL100020 05/28/10 05/28/11 PR MISES (ERa occurence) '
_, _. _ CLAIMS MADE V OCCUR MED EXP (Any one person)
A
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY ,.•, PROJECT _ LOC
AUTOMOBILE LIABILITY
. – ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON OWNED AUTOS
GARAGE UABILITY
ANY AUTO
EXCESS/UMBRELLA LIABILITY
• OCCUR _ CLAIMS MADE
•
_ DEDUCTIBLE
•
• „ RETENTION $
WORKERS COMF1ErNSATION ND
• EMPLOYERS' LIABILITY
ANY PROPRIETOR / PARTNER / EXECUTIVE
OFFICER / MEMBER EXCLUDED?
• If yes, describe under
SPECIAL PROVISIONS book__
OTHER
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP /OP AG
Fire Damage Liability
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
-Per accIden9
•
AUTO ONLY - EA ACCIDENT
OTHER THAN F,LAACC
AUTO ONLY AGO _ •
EACH OCCURRENCE
AGGREGATE
5,0001
200,0001
G 100,0001
50,000
•
7..QYLIM S —gR ".
E.L. EACH ACCIDENT
E.L DISEASE - EA EMPLOYEE;
EL DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES ! EXC. Ii ONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER
Miami Shores
10050 NE 2nd Avenue
Miami Shores, FL 33138
I _. ._ FAX.. 305-750-8972
ACORD 25 (2001/08) QF
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO
THE LEFT, BUT FAILURE= TO 00 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
— AfitHORIZED REPRESENTATIVE
ACORD CORPORATION 1988
Gogo
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Heike Wiese
PERMIT #:13 -SC- 1302012
APPLICATION #: AP994490
DATE PAID:
FEE PAID:
tECEIPT #:
DOCUMENT #: PR835478
PROPERTY ADDRESS: 149 NW 93 St
Miami, FL 33150
LOT: 17 & 18 BLOCK: 133 SUBDIVISION: Miami Shores Sec 6
PROPERTY ID #: 11- 3101 - 033 -0850
[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 [ 900 ] GALLONS / GPD Septic CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 1 GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TATK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSESIPER 24 HRS #Pumps ( 1
D [ 300 ] SQUARE FEET SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [ ] TRENCH [X] BED ( ]
N
F LOCATION OF BENCHMARK: F.F.E.: 13.0' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 28.803 [1 INCHES 1/ FT ][ ABOVE A BELOWbBENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 64.80 1 [1 INCHES I FT ] [ ABOVE A BELOW li BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED:
T
H
E
R
0.00 ] INCHES
EXCAVATION REQUIRED: [ 48.00] INCHES
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 300 sf of
drainfield in bed configuration. 4- Install 12" of slightly limited soil under the bottom of drainfield. 5- Perimeter of excavation
area shall be at least 2 ft wider and longer than the proposed absorption bed. 6 -Invert elevation of drainfield to be no Tess
than 8.10' NGVD. 7. Bottom of drainfield elevation to be no less than 7.60' NGVD. REPAIR
THIS PERMIT IS NOT FOR ADDITI. MO#41-DA0C COUNTY HEALTP DgpAnirmetrr
SPECIFICATIONS
APPROVED
Y:
PEDRO N OSPINA
TLE:
DATE ISSUED:
P • N OBpina
02/18 2011
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
v 1.1.4
AP994450
Dade CHD
EXPIRATION DATE: 05/19/2011
5E836509
Page 1 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE :DISPOSAL SYSTEM CONSTRUCTION PERMIT
r Permit Application Number
Scale: Each block re
resents 5 feet and 1 inch= 50 fee
there are no pertiaent.features on adjacent properties and across
the street that may affect the systeninstallatlon.
--r
RTII - SITE PLAN- —
i49 ,0t .0 93
f 66u4..111 �-
1-"•"i.
4-4 i
s. >a4
a ^aMi j .. r ea '_ � .:- •Lf?f� +' i -� ,
„Ai jeitZfe. i
DryR0 GPI .
i_y...�. �. 1- -.
•
�nrwwi:tt
310
',A.wi 4OSN
Notes:
(/c c)O c 4--. /a ) "— f- )
Site Plan submitted by:
Plan Approved
By
Signature
Not Approved
Date
Title
County Health Departnne
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
Registered Septic Tank Contractor
DAVID NUBY
401 SW 12 AVENUE
DANIA FL 33004
NU-BLACK SEPTIC & DRAINFIELD
COMPANY
Business Authorization: SA0041170
SR0931118
Registration Expiration Date: September 30. 2011
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