PL-11-1679Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 164361
Permit Number: PL -9 -11 -1679
Scheduled Inspection Date: December 14, 2011
Inspector: Hernandez, Rafael
Owner: SEGRERA, VERONICA
Job Address: 314 NE 94 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: A AMERICAN SEPTIC & PLUMBING
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number (786)797 -1985
Parcel Number 1132060136190
Phone: (305)866 -5600
Building Department Comments
DRAINFIELD REPAIR
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
HRS IN FILE
***PLEASE CALL NORMAN BEFORE INSPECTION***
December 13, 2011
For Inspections please call: (305)762 -4949
Page 11 of 53
t
1
y
0
P .
•
=�x
`'0.4%
CHECKED [X] ITEMS ARE
TANK INSTALLATION
(01] TANK SIZE [11"C S`C" [2]
[02] TANK MATERIAL < - »'•
[03] OUTLET DEVICE
[04] MULTI - CHAMBERED [Y./ N
[05] OUTLET FILTERT:0"--
[06] LEGEND-S-3 r J' CO ~•:9,9-47
[07] WATERTIGHT
[08] LEVEL •
[09] DEPTH TO LID ;
DR4,INFIELD INSTALLATION
[10] t AREA [1 ]WC 40 [2] "3 O SOFT
[11] DISTRIBUTION BOX HEADER d!
[12] NUMBER OF DRAINLINES ey
[13] \ DRAINLINE SEPARATION 3L: ° -
[14] t, DRA, NLINE S ,Q„]
[15] DEPTH is OVER /
[16] ELEVA [ABO
[17] SYST OCATION
[18] DO PUM
[19) AG EGATE
[20] A 43EGATE
]
[21 ] AG�EGATE
FILL / EXCA A ION MATERIAL
[22] FILL AMOUNT ,
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
SETBACKS
[27] SURFACE WATER FT
[28] DITCHES FT
[29] PRIVATE WELLS FT
[30] PUBLIC WELLS FT
[31] IRRIGATION WELLS FT
[32] POTABLE WATER LINES 1 0 FT
[33] BUILDING FOUNDATION / FT
[34] PROPERTY LINES ✓ FT
[35] OTHER FT
� a
FILLED / MOUND SYSTEM
[36] DRAINFIELD COVER
[37] SHOULDERS
[38] SLOPES
[39] STABILIZATION
ADDITIONAL INFORMATION
•UNOBSTRUCTED AREA
STORMWATE_ R RUNOFF
ALARMS
MAINTENANCE AGREEMENT
BUILDING AREA
;LOCATION CONFORMS WITH SITE PLAN
FINAL SITE GRADI G
CONTRACTOR
OTHER
[40],,
[41]
[42].
[43]
[44]
[45]
[46]
[47]
[48]
ABANDONMENT
[49] TANK PUMPED 1 l /e
[50] TANK CRUSHED & FILLED / I /fi"
CONSTRUC ON [APPROVE DISAPPROVED]- 1�
FINAL SYS'T ht [APPROVE@4DISAPPROVEDJ
•
DH 4016 (Page 2), 10/97 (Previous Editions May Be Used)
Stock Number. 5744-002-4016-4
CHD DATE. 6? 6 )
CHD DATE-® 7-
Page 2 of 3
PT 1: Applicant
STATE OF FLORIDA,
DEPARTMENT OF HEALTH
ONSITE SEWAGE TRRMEKT,AND DISPOSAL SYSTEM
CONSTRUCTION INSPECtga AND FINAL APPROVAL
APPLICANT: -44 -
AGENT: te's-
PROPERlY ADDRESS: ff
PERMIT NO .44-
_ _DATE NUD:
FEE PAID
RECEIPT It*
BDIVISION:
• DFIEMEG:. TX] ITEMS ARE NOT IN
ANCL WITH grAft.gt,;till • RULE • AND MUST. BE : 0:41
TANK -INSTALLATION
(- ] [01] TANK SIZE (1] -'17•7''' • [2]
[ ] -102] TANK MATERIAL'
] [03] OUTLET oEllitt-
[ ] [Y
I ET FILTER [- 1 [31]
PI LEGEND " "" > [ 1 [321
[ 1 [071 - WAIIH t !GMT
[ 3 [08] LEVEL
09] DEPTH-TgrUD
DRAT PEW- INSTALLATION
r1rr AREA [1
[11] ,Rtifitu-rioN BOX _HEADER
] [12], NLIMBER OF DRAINUNES
DRAINUNE SEPARATION -
1 [14] DRIUNU E SLOP
vs] DEPTH
• [ r
[ 1. [17] SYS
( 4 191 DP
f 1 11
I I Rol
I [21]
SETBACKS •
[ [27] SURFACE WATER"-
-
RIVATE ii97014-*
[ [30]
= = =
PUBUC
IRRIGATION INELUStIrr.:4
POTABLE WATER UNES fC Fr.
ButL.DINoTouNDkilo#,:,:, FT •.
PROPERTY UNES 5 Fr
(353 OThER . .
. .; i,70--#ILIW„:,!1 Fr . *
•
;--' FILLEDik401/NDSYSTIMOOFT:' •
DRAINFIEU3 COVER
Fr
I-171 SH5LIZAVWcw"'"
[38] SLOPES
ER
TON
I
I
I 1
[ I
1. [43]
f.'144T
'1 1 [451
I [461
t 1 [47]
[ 1 [48] OTHER
ABANDONMENT
[0*, [491- TANK PUMPED-- -,1,-/Ahki
(Oik, [50] TANK CRUSHED & FILLED.Lelf '6/
-.4001r,
_
[39] STABILIZATI
ADDMONAL INFORMATION
[40]
[41]
[421
C
D
-FLLLEXCA4 ON MATERIAL
[22] FILL AMOUNT 65/
(23] FILL TEXTURE.
] [24] EXCAVATION. DEPTH
1 [25] AREA REPLACED
• [ 1 [26] REPLACEMENT MATERIAL
EXPLANATION OP iIKKATIONSINgiARKS:
[ 1
[
• I - 1•
untosamogrgo.A.w.,.:-,crAr
STORMWATER RUNOFF
ALARMS
MAINTENANCE AGREEMENT
LOCATION CONFORMS Wff_171 SITE PLAN
FINAL gift 0 • ...
CONTRACTOR
1
CONSTRUCT N [A1;171SAPPROVED]:
FINAL SY
APPROV
I
eop CHP DATE I 1
ISAPPROVED]: e?, CHD DATE: q
01-14016 (Page 2), 1W97 (Previous Editions May Be Used)
Stock Number 8744-002-4016-4
PT 1: Applicant
PT k InstalleaContractor
PT 3: Building Depart/non/ .
- PT 4: Health D0ParbuslIt
.
&odd rap.
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.
•
111111111111111111121111111111111111111111 '"'' 1' L111111111111
�1111111111__
IBM NilNIIIIIIIII MIME 11E11 II
O.,
arteS
bill
Mil iiiiiiiiMS1111111111111111111111Mt.
VII wc t
tt,
1111 .
Irliffl 11111111,V4t1:',21111111111111rif
E a _ _ - -_ MGM -_
R
- -
Illiiiiiiminaranum I I I
■ it
4474
Notes: e i o s i i y •°IOO - L @ 4 \ t rt t" try ft—DAN i p -
kC0. U r . r goo ,sue %t e - .-j-
kTe-iteM 4,-N etck c c 1 c.l- ro v.2 4 (4-ex •
Site Plan submitted by:
Plan Approved
BY
mot- oDvt3
Date °t-'-11
County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015,10196 (Replaces HRS-H Form 4016 which may be used)
(Stock Number: 5714-002- 4015 -6)
Page 2o14
1
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138 -0000
Phone: (305)795 -2204
Parcel Number
Applicant
314 NE 94 Street
Miami Shores, FL 33138-
1132060136190
Block: Lot:
ORCAR LONGA
1
Owner Information
Address
Phone
Cell
ORCAR LONGA
314NE94ST
MIAMI SHORES FL 33138 -2832
(954)254 -0491
Contractor(s) Phone Cell Phone
A AMERICAN SEPTIC & PLUMBING (305)866 -5600 (786)236 -5599
Valuation:
Total Sq Feet:
$ 1,500.00
0
1
Type of Work: SPETIC AND DRAIN
Type of Piping:
Additional Info:
Bond Retum :
Classification: Residential
Scanning: 1
Fees Due
Bond Type - Contractors Bond
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$500.00
$1.20
$2.25
$2.25
$0.40
$300.00
$3.00
$1.60
$810.70
Pay Date
Invoice #
09/13/2011
09/19/2011
09/19/2011
Pay Type
PL -9 -11 -42013
Credit Card
Check #: 3396
Credit Card
Bond #: 2067
Amt Paid Amt Due
$ 50.00 $ 760.70
$ 500.00 $ 260.70
$ 260.70 $ 0.00
1
Available Inspections:
Inspection Type:
HRS Approval
Final
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS 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. Futhermore, I authorize the above -named contractor to do the work stated.
September 19, 2011
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
Date
September 19, 2011 1
1
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
c \‘5\ C 1�' INSPECTION'S PHONE NUMBER: (305) 762.4949
BUILDING K Permit No. RA j '°l 1 ((ci
PERMIT APPLICATION
FBC 20
Master Permit No.
Permit Type: PLUMBING 1 m le (12-746C4-
�
OWNER: Name (Fee Simple Titleholder): N"ro ' W re
" Phone#: 12"~ 4--
Address: 3 (L( N €44-1 \fl
City: IDYL e Sim re S
State: Zip: 3 3 lie
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: 314 k) q14 Stf ;e+-
City: Miami Shores County:
Folio/Parcel #: it 3 z-ao b( 3 ° (p (4 O
Miami Dade
zip: 35138
Is the Building Historically Designated: Yes NO
Flood Zone:
CONTRACTOR: Company Name: A' ftYnC-S✓it,Aan Te 47141M1o1'Ane#: 91042 ADO
Address: 1 o-SS 1113 Cettifl i3 t ! cip
City: 1. 1Y11 et-m1 State: -- Zip: 3315 1
Qualifier Name: hJ l ikro ® Phone#: 3 O f(a (o "woo 0
State Certification or Registration #: $ 6 )O qt'('} Certificate of Competency #:
Contact Phone#: SLX 6490i) Email Address: lrt rte i ® & curt-rack" -P4t~' 0' -'q t-1^C-' LeryK,
DESIGNER: Architect/Engineer: 14 fl Phone#:
Value of Work for this Permit $ 413 N Square/Linea• Footage of Work:
Type of Work: DAddress DAlteration
DNew
Description of Work: (4\ —Ree t4 kip& LT-- 4'".
pair/Replace DDemolition
..................................7 .... .... ... ... ... ......... .....
Submittal Fee $ Permit Fee $ /.O CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 9 k)O . 7 0
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 I -the absence of such posted notice, the
inspection] wi not be app , ved and a reinspection fee will be charged
er or Agent
The foregoing instrument was acknowledged before me this day of __ , 20 �, by �' �� `�4L who is personally known to me or who has produced ft D- As identification and who did take; an lath)...
NOTARY PUBLIC:
OTARY PUBLIC -STATE OF FLORIDA
. Jazzmin Cruz
Commission # EE030407
Sign:
Print
1 416"
• �... •
" /• »mTaao ATLANTIC soxDDrGCO,nvc
My Commission Expires:
APPROVED BY
The foregoing instrument was acknowledged before me this' �"
day of , 20 2, by Vv1"1't,T3- ' hroo
who is personally known to me or who has produced ft.
PL T- C-fISC- as identification and who did take an oath.
Plans Examiner
Structural Review
(Revised 07 /10/07)(Revised 06 /10/2009XRevised 3/15/09)
NOTARY PUB C:
Sign:
Print
My Commission Expires:
Y PUBLIC-STATE OF FLORIDA
Jazzmin Cruz
:Commission # EE030407
8, 2014
11 ATLANTIC BONDING CO., MC.
Zoning
Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
OPERATING PERMIT
For GSM" Service and Septage Disposal,
Issued To: A American Septic & Plumbing Inc.
12555 Biscayne Blvd
Ste 970,
orth Miami, FL 33181
Billing ID: 13- B1D- 1705100,
Permit Number 134G-00188
County: 13 -Dade
Issue Date: 07/01/2011
Permit Expires On: 06/3012012
The facility s own above has been inspected by a duly authorized representative of the Department of Health, and was found
In conforman with those rules promulgated by the department under the authority of Chapters 381, 386 and 489 Part III,
Florida S es, and set forth in Rule 64E-6, Florida Administrative code.
This permit g nts authority to operate the above referenced facility, service, or system in conformance with department rules
and the cond tions of operation shown below. This permit is revocable, upon service of notice, when it is d rmined by the
Hoy:. �, RE.
May
department at the operational conditions and department standards are not being maintained. Ni0
Issued by: M i -Dade County Health Department
17:25 NW 167 St , Miami, FL 33056
DO NOT DETACH HERE
DO NOT SEPARATE FROM OPERATING PERMIT
STATE OF FLORIDA
DEPARTMENT OF HEALTH
CONDITIONS OF OPERATION
For. OSTDS - Service And Septage Disposal,
Issued To:
A American Septic & Plumbing Inc.
Billing ID: 13- BID4705100
Permit Number. '13-0G-00188
Permit Expires On: 06/30/2012
The operatin permit for the facility shown above has been issued with the following conditions of operation:
This permit is for a septage disposal service. Truck(s) shall be presented for inspection upon request by the Department.
DISPLAY OPERATING PERMIT AND CONDITIONS OF OPERATION IN A CONSPICUOUS PLACE
DETACH HERE - RETAIN THIS PORTION FOR YOUR RECORDS
STATE OF FLORIDA
DEPARTMENT OF HEALTH
RECEIPT
For OSTDS - Service And Septage Disposal,
Issued To: A American Septic & Plumbing Inc.
12555 Biscayne Blvd
Ste 970,
North Miami, FL 33181
Mailed To: Mark Woodard
12555 Biscayne Blvd
Ste 970
Biscayne Park, FL 33181
RETAIN FOR YOUR RECORDS
(Non - Transferable)
Billing ID: 13- BID - 1705100
Permit Number 13- 00188:
County: _13 - Dade
Issue Date: 07/01/2011
Amount Paid: 290.00
Date Paid: 08/01/2011
CheckNumber:
Receipt Number 13- PID- 1682408
Operator ID: SardinaYX
Fee paid by: A American Septic & PIu
Issued By: Miami -Dade County Health Department
AR L'5 CERTIFICATE OF LIABILITY INSURANCE
DATE `�° '"'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorses. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsoment A statement on this certificate does not confer rights to the
certMcate holder in lieu of endorsement(s).
PRODUCER 954 - 318-2469 954 - 318 -2474
INFINITY INSURANCE SOLUTIONS
6412 N UNIVERSITY DRIVE
SUITE 132
TAMARAC. FL 33321
Icr INFINITY INSURANCE SOLUTIONS
LArPH N, nEro. : 954 -318 -2469 1 IFA►c, Not 954 - 318-2474
i : INFO @IISFL.COM
mum
AFFORDING COVERAGE
NAIL Ix
INS 305 -919 -9514 305-891 -6905
A AMERICAN SEPTIC & PLUMBING, INC.
12555 BISCAYNE BOULEVARD, #970
NORTH MIAMI, FL 33181
INSURER A: ASCENDANT INSURANCE CO.
INSURER B: SUA INSURANCE COMPANY
GL- 37126 -0
INSURER C:
04/18112
INSURER D:
$1,000,000
$
INSURER E:
PREMISES )
INSURER F :
CLAIMS -MADE
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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_ OMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
MGR
LTR
TYPE OF fl SURANCE
AWL
INSR
SUMR
WVD
POLICY NUMBER
- POLICY EFF
II WYYYY)
POLICY ETIP
IMM1DWYYYY)
LM STS
A
GENERAL
UABILITY
COhUdERClAL GENERAL Llaeltinr
OCCUR
GL- 37126 -0
04/1811
04/18112
EACH OCCURRENCE
$1,000,000
$
✓
PREMISES )
CLAIMS -MADE
✓
MED EXP (Any one Persurn
$ 5 000
PERSONAL &ADV INJURY
$1,000.000
$ 2.000.000
GENERAL AGGREGATE
GEM_
AGGREGATE LJMIT
POLICY n
APPLIES PER
PRODUCTS - COMP/OP Atm
$ 1,000,000
$
71
I j I LOC
AUTOMOBILE
UABIUTY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
.
COMBINED SINGLE OMIT
(Ea acddent)
$
BODILY INJURY (Perpetual)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Pet accident)
$
$
$
_
UMBRELLA LIAR
EXCESS UAB
_
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
DEDUCTIBLE
RETENTION S
$
$
B
WORKERS
AND
COMPENSATION
EMPLOYERS' HAMMY
NIA
WSAUIEC72193901
02103111
02/03/12
' TORYSLIRS I I ER
EL EACH ACCIDENF
$ 100,000
UUgq�,tl� In
D> f IOeN OF OPERATIONS
DISEASE - EAEMPLOYEE
$ 100,000
below
EL DISEASE - POLICY LIMIT
$ 500,000 ,
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Addinona' Remarks Schedule, If more space Is required)
98482- PLUMBING, COMMERCIAL & INDUSTRIAL
98483- PLUMBING, RESIDENTIAL OR DOMESTIC
91585- SUBCONTRACTOR CONSTRUCTION, ERECTION, REPAIR OF BUILDINGS
5183- PLUMBING NOC AND DRIVES (WC)
CERTIFICATE HOLDER
CANCELLATION
MIAMI SHORES VILLAGE
10050 N.E. 2ND AVENUE
MIAMI SHORES, FL 33138
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORED REPRESENTATIVE
m 4988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD
For: OSTDS - Service and ATU Maintenance
Issued To:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
OPERATING PERMIT
American Septic & Plumbing, Inc.
2555 Biscayne Blvd
70,
iami, FL 33181
Billing ID: 13-"BID- 1715112,
Permit Number: 113=QG -01132 "
County. " 113 -Dade
Issue Date:'" 07/01/2011
Permit Expires On: 06/30/2012
The facility s own above has been inspected by a duly authorized representative of the Department of Health, and was found
in conforman with those rules promulgated by the department under the authority of Chapters 381, 386 and 489 Part 111,
Florida S es, and set forth in Rule 64E-6, Florida Administrative code.
This permit grants authority to operate the above referenced facility, service, or system in conformance with d -; ent rules
and the conditions of operation shown below. This permit is revocable, upon service of notice, when it is det ed by the
department that the operational conditions and department standards are not being maintained. NICK
Mi
I-1
Issued by: M'ami -Dade County Health Department
1725 NW 167 St , Miami, FL 33056
DO NOT DETACH HERE
DO NOT SEPARATE FROM OPERATING PERMIT
STATE OF FLORIDA
DEPARTMENT OF HEALTH
CONDITIONS OF OPERATION
For OSTD - Service And ATU Maintenance
Issued To:
A American Septic & Plumbing, Inc.
(Non Transferable)
Billing ID: 13= BID - 1705112 '-
Permit Number: - 3 QG -01132
Permit Expires On: 06/30/2012
The operatin permit for the facility shown above has been issued with the following conditions of operation:
This permit is for an ATU Maintenance Entity. Entity shall conduct a minimum of 2 inspections per year for each residential
system and r contract and 4 inspections for each commercial system. Entity shall make all records available for a
Departmen inspection once per year. Entity shall maintain a valid certificate with the manufacturing company of all systems
under con ct.
DH-4013 (03/97)
DISPLAY OPERATING PERMIT AND CONDITIONS OF OPERATION IN A CONSPICUOUS PLACE
For
DETACH HERE - RETAIN THIS PORTION FOR YOUR RECORDS
STATE OF FLORIDA
DEPARTMENT OF HEALTH
RECEIPT
OSTDS - Service And ATU Maintenance
Issued To: I A American Septic & Plumbing, Inc.
12555 Biscayne Blvd
970,
Miami, FL 33181
A American Septic & Plumbing, Inc.
12555 Biscayne Blvd
Ste 970
Biscayne Park, FL 33181
Mailed To:
RETAIN FOR YOUR RECORDS
(Non - Transferable)
Billing ID: 13-BI D- 1705112
Permit Number 13-QG41132>
County: 13 Dade
Issue Date: 07/01/2011
Amount Paid: 50.00
Date Paid: 08/01/2011
CheckNumber:
Receipt Number 13 -PID- 1682409
Operator ID: SardinaYX
Fee paid by: A American Septic & Plu
Issued By: Miami -Dade County Health Department
CERTIFICATE OF AUTHORIZATION
The Florida Department of Health hereby certifies the business or entity
named below has satisfied the requirements of Part III, Chapter 489, Florida
Statutes, for septic tank contracting and has been duly authorized by the
department to provide septic tank contracting services under the name of:
A AMERICAN SEPTIC & PLUMBING, INC.
Authorization Number
Rick Scott, Governor
DOH 4079, 1, 1997
09/13/2011 11:11 FAX
STATE or FLORIDA
DEPARTMENT OF SSAZTE
QNSITE BENUE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PEST
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT! Veronica Segrera
PROPERTY ADDRESS: 314 NE 94 St Miami, FL 33138
LOT: 10 -11
RI001 /001
MOST s: 13-SC-1368287
APPLICATION II: AP 1046737
DATE PAID:
FEE PAID:
RECEIPT i):.
Do0OMENT 0: PR064196
fix: 4e
PROPERTY In 4: 11,3208. 0134190
9U>5DxvisxoN: Miami Shores Sec 1 Amd
(SECTION, Tow rasp, RANGE, PARCEL NUMBER]
[OR TAX ID SINEW
SYSTEM MUST SE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION
391.0065, F.S., AND CRAFTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SYSTAN DOES NOT GUARANTEE
SATISFACTORY PERWORMANCE FOR ANY SPECIFIC PERIOD o$ TIME. ANY CAE IN MATERIAL PACTS,
W!ICH SERVED A8 A BASIS FOR ISSUANCE OF TRIS PERMIT, REQUIRE TNE APPLICANT TO MODIFY TEE
PERMIT APPLICATION. SUM MODIFICATION, MAY AEBULT EE TUTS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OB THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING H$QUD FOR DEVELOPMENT or TX18 PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T
A f
N [
R
1,050 ] GALLONS / GPD
0 ] GALLONS / GPD
0 1 ELM= GREASE relatRCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY
Septic
D f 300 ] SQUARE FEET
R [ 0 3 SQUARE BEET
A TYPE SYSTEM: [x] STANDARD
x CONFIGURATION: [R] TRENCH
CAPACITY
CAPACITY
EMILICCSUM CAPACITY SINGLE TANK:1250 GALLONS]
]GALLONS 5( ]DOSES PEA 24 PE *Pumps [
in trench configuration aYaM Ear
SYSTEM
( ] FILLED [ ] MOUND
[ 3 MD f ]
N
13,
s LOCATION of BENCEMARN: FFE : 11.2' NGVD ' I
• EZmvnTZON OF PROPOSED SYSTEM SITE [ 13.20 ] [1 INCHES r t' j L ABOVE notgranicrammixonactraz
E BOTTOM OF DRAIINFIELD TO BE [ 44.20 FT IL ABOVE 4 Emmet flasuscameasciaamcwana
L
D FILL REQUIRED: ( 0.001 INCREs
0
T
- Install 1050 g septic tank.
- Install 300 so ft drainfield in trench configuration.
- Elevation of bottom of drainfield to be no less than 7.51' NOVD.
- Not for additions
The licensed contractor installing the system is responsible for installing
the minimum category of tank in accordance with s. 64E- 6.013(3)(f), FAC.
EX VATION REQUIRED: [ stop] xA1CHES
POINT
POINT
The contractor (or designee) is required to perform a
soil boring adjacent to the drainfieid excavation at the
time of final Inspection prior w Final Approval, the DOH
results hhe original site eevaluation rsubmi compare the
reinspection fee will be assessed if the contactor is not
et the Jobsite at the arranged time.
SPPCZPXCr►Tx0Na Br:
APPROVED 87r:
William Woodard
r
Joe
DATE ISSUED: 09/x:/2011
TITLE:
Engineer Specialist II
DM 4016, 08/09 (0baol- ?`e all previous editions which may not be used)
Inaorporatsd: 64E -6. , FAC
v 1.1.4
AP1D46737
MI:RATION DATE:
83851938
Dade C�
12/12/2011
Pago 1 of 3