PL-11-1610Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 163974 Permit Number: PL -8 -11 -1610
Scheduled Inspection Date: September 21, 2011
Inspector: Hernandez, Rafael
Owner: RAYBURN, RALPH
Job Address: 250 GRAND CONCOURSE
Miami Shores, FL
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060136220
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 IN FILE
September 20, 2011
For Inspections please call: (305)762 -4949
Page 20 of 34
DIVISION OF
Environmental Health
Florida Department of Health
Miami -Dade County Health Department
OSTDS /Well Division
11805 SW 26 St. • Miami, FL 33175
Inspector ,12-
�� ---- -�
Address
Comments;
Date %'" 2-
TDS #14d!O Y.-2-7,6 3
Signature
0
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 �J �1
k OWNER: Name (Fee Simple Titleholder): /- 4( P/ /. /7M/2164°
Sc/
AUG 302011
Permit No. ?L 1 (-1(010
Master Permit No.
Address: .26D ��� .1 C C tf C®C9� -s
City: /fd/i11 t I �i � E State: /®4
Tenant/Lessee Name: �,% 1 J
Email: g I 01 CcWt (Y (A l I S®CuT�`. a �..e_f-
JOB ADDRESS: ` ` AJ° ( JCo(i
City: Miami Shores County:
Folio/Parcel #: /1 - 3 2_06 -DI 3 �=' 2
Is the Building Historically Designated: Yes NO
Phone #: 30�- `6 /kd d
Phone #:
Zip: 33/ 39
Miami Dade
Zip:
Flood Zone:
f�,<
CONTRACTOR: Company Name: h 4e' ; � Phone #: CC /- 6 £3
359 .S. St el 7
Address:
City: H, Ira In 0, State: 194®
Qualifier Name: T .ik
Zip: 33.0a3
Phone #:
State Certification or Registration #: '� O'3 1 12 C z- Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
22 s+� Square/Linear Footage of Work: 2 S
New Repair/Replace ❑Demolition
Ree o,-, tog
Value of Work for this Permit: $ GO
Type of Work: ❑Address ❑Alteration
Description of Work:
* * * * * * **
Submittal Fee
Scanning Fee $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
*** * * ******** ** *** ******** *** Fees * *** ********** *** * *** * * ** * ** * ***** * *********
Permit Fee $ 05a CCF $
Radon Fee $ DBPR $
TOTAL FEE NOW DUE $
Bonding Company's Name (if applicable)
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) - 7
Mortgage Lender's Address P0,g0Y 7'8 (tzd
City /9.4t i�%jl`
aZc.11..
State 40 ZIOA.1.4
zip R. O62 - g y
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.
Signature 1 44 Signature
0 Owner or Agent
tk
P Y I p d �r �v p J L9S
Contractor
y� f Q �/ day of ft,qu� , 20 I � , by �° ,,t, Roy I� U Y Y\ , day of l� �'�9� G , 20 AIL, by �,,��="�, /o/ 3A� ho is ersonall known to me or who has roduce ( ho is ersonally known to me or who has produced we D
Lt ak (R.1 b5" 1'2 A-s dentli ion and who did t NOTARY PUBLIC: ``a�oTS /q 1 Wtr7 ec�i a
The foregoing instrument was acknowled ed before me this The foregoing instrument was acknowledged before me this
Sign:
Print:
J- 1st
My Commission Expires:
$ a$ sacakak*x** akakXeakokakakakaksk *akakakak3.aakakakak
APPROVED BY
as identification and who did take an oath.
\%\u911 n u1111,
NOTARY PUBLIC
Sign:
Print:
My Commission Expires:
,10 do
,`\mod 06291 t
lit 00
p' ci)�
(7118 fitif .10 N
. .0
41(111119110
:k *Aaa:saASA`.******* sleek *a:+k*: *** ale*: k*ek: k: ksh: kskskx *neskati= ks ksku,: sk9Faeskx akae= ktleskaEek:;s sksksksksk ****sk$akskskASSksk***
l/
Plans Examiner
Structural Review
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Zoning
Clerk
STATE dF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT RECEIPT #:
DoctMENT #: PR853264
PERMIT #: 13-SC-1366541
APPLICATION # : AP1045763
DATE PAID:
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT:
Ralph Raybum
PROPERTY ADDRESS: 250 Grand Concorse St Miami, FL 33138
LOT: 16
BLOCK: 46 SUBDIVISION:
PROPERTY ID #: 11- 3206 - 013 -6220
[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 [
900 ] GALLONS / GPD Septic
0 ] GALLONS / GPD
0 ] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY
D [ 225 ] SQUARE FEET
R [ 0 ] SQUARE FEET
A TYPE SYSTEM: [x] STANDARD
I CONFIGURATION: [x] TRENCH
CAPACITY
CAPACITY
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
in trench configuration SYSTEM
SYSTEM
[ ] FILLED [ ] MOUND
[ ] BED [ ]
N
F LOCATION OF BENCHMARK:
FFE : 11.9'NGVD
[ 24.00 ] [ INCHES I FT ] [ ABOVE BELOW 1 BENCHMARK /REFERENCE
[ 54.00 l [I INCHES I FT 3 [ ABOVE 4 BELOW h BENCHMARK /REFERENCE
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ 30.00] INCHES
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY: AiI
Jos =,F. R
DATE ISSUED: 08 1• /2011
POINT
POINT
- Install 225 sq ft drainfield in trench configuration.
- Elevation of bottom of drainfield to be no less than 7.40' NGVD.
- Existing 900 g septic tank, to remain.
- Not for additions
The contractor (or designee) 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
reinspection fee will be assessed if the contractor is net
at the jobsite at the arranged time.
Teresa J Solo
TITLE' Master Septic Tank Contractor
DH 4016, 08/09 (Obsol
Incorporated: 64E -6.
s all previous editions which may not be used)
03, FAC
v 1.1.4
AP1045763
EXPIRATION DATE: 11/28/2011
6E851153
Page 1 of 3
` TiP E STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITEPLAN
Scale: Each block represents 10 feet and 1 inch = 40 feet.
Notes:
`p ,._,- 0, " 2 s` l ..-V\C Cor1C{ ;`y d 1,
(41C r - a twol€: 3 -7
Site Plan submitted by:
Plan Approved
By
C :'�'�f11��
Signature
Not Approved
72;8
� s
p -am -� �� (7
e
Date'
County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015, 10/96 (Replaces HRS -H Form 4016 which may be used)
(Stock Number: 5744-002-4015-6)
Page 2 of 4
RI
NI
11
'
11
111
11111121.
1
f
111111MMIZEINIEMBill
1111119111
III
11111111EMEIN
EMI
IMMIIIIIIMONIEMBIl
ill
MEE
--`1"---
a �
9 c
rk
�
i
,
Diu
leli
iio
ti.N
E
1
•••
r,-
B�rI9
r)-v
-ae
--f,--'c
i
1
11111111111111
1
EM=
°
�v
IMU.■■■■■�
■II
t.
TONEININIMMENErril
MI
M
_.•••••u,••MI•1111
111111111111M-ANA' IN
Notes:
`p ,._,- 0, " 2 s` l ..-V\C Cor1C{ ;`y d 1,
(41C r - a twol€: 3 -7
Site Plan submitted by:
Plan Approved
By
C :'�'�f11��
Signature
Not Approved
72;8
� s
p -am -� �� (7
e
Date'
County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015, 10/96 (Replaces HRS -H Form 4016 which may be used)
(Stock Number: 5744-002-4015-6)
Page 2 of 4
BUILDER'S BOND
Issued: 08/31/2011
Amount: $ 300.00
Bond #: 2065
Permit #: PL -8 -11 -1610
RALPH RAYBURN owner of property, in consideration of the issuance to me of a permit or permits to construct or repair a building or buildings at the following address:
250 GRAND CONCOURSE Miami Shores FL
do hereby deposit the sum of: $300.00
and I agree that when such construction has been completed by me, within the meaning of the ordinances of this district, I will clear all premises and repair any
property damaged by me, used for the deposit of material or equipment in the construction or repair and that, if I do not so clear and repair such premises immediately
upon the completion of construction within the meaning of the ordinances, the district may clear and repair the same and pay the cost of such clearance and repairs
out of the Builder's Bond, and return the remainder to me; and that, if I shall clear and repair the property immediately, then the Builder's Bond shall be returned to me.
WITNESS AND DATE: 08/31/2011
Signature
INSTRUCTIONS TO BUILDER: When the above mentioned construction is completed and the premises are cleared and repaired, take this bond to the District
Building Department for a refund of your money in accordance with the above agreement.
BUILDING INSPECTOR'S APPROVAL
I hereby certify that the construction contemplated under this Bond, has been completed and that the builder thereof has caused the surrounding premises to be
cleared and repaired in as good condition as they were before commencing said construction.
WHEN CLEARED AND REPAIRED BY THE DISTRICT:
Amount of Bond:
Cost of clearing and repairs done by District:
Balance due Builder:
$
Cancelled:
By:
Building Official
Date
Bond refund payable to applicant only.
($10.00 CHARGE IF BOND IS LOST OR DAMAGED)