PL-11-2211Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 167134
Scheduled Inspection Date: December 09, 2011
Inspector: Hernandez, Rafael
Owner: ARELLANO, LISA
Job Address: 69 NW 99 Street
Miami Shores, FL 33150-
Permit Number: PL -11 -11 -2211
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1131010180490
Phone: (954)963 -0082
Building Department Comments
PUMP ABANDON AND REPLACE SEPTIC TANK WITH
NEW 900 GALLON SEPTIC TANK NEW 150 SQ FT
TRENCH 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.
December 08, 2011
For Inspections please call: (305)7624949
Page 12 of 14
DIVISION; Health
iranmenta
Flo partment of Health
Health Department
ami Dads DSI�Nell Division
uses SW 36 St. • Miami. FL 33175
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's Name (Fee Simple Titleholder) U SR. R060 I oP'hone # °3O.S 7I If 2_ O Se2.
Owner's Address %mil vU (3)®1
City 11/4-11; q reN S ►eS State
9 26111 i , �
NOV 2
BY: —.1.1.S.._ e- - - - - -_
Permit No. Pi fl-.da
lt
Master Permit No.
Tenant/Lessee Name
Email
Zip 5 -34
Phone #
Job Address (where the work is being done)
City Miami Shores Village County Miami -Dade
FOLIO / PARCEL # l' as — 0 I -' ® lfc!
Is Building Historically Designated YES N0_1/
Zip
331S0
Flood Zone
Contractor's Company Name St41 sADti do r '`C, C rai is Phone # GC' ' 66 33
Contractor's Address 9 ea° x ,58 GS
City p 4,400 ci State r2- Zip 3-508
Qualifier Name t°S0 f o rra®, Phone #
State Certificate or Registration No. S 0 q 1 ( 26 2- Certificate of Competency No.
Contact Phone
,•
E -mail
Architect/Engineer's Name (if applicable) Phone #
Value of Work For this Permit $
Type of Work: ['Addition
Describe Work:
40-00 Square / Linear Footage Of Work: 150
['Alteration
❑New A Repair/Replace ❑ Demolition
\vmp 4- MO qnCtio s) a Ptp(9Ce b e,r)
G --t K w ( ).14_44 900 gI1i.or,
reocti of - -eta
**********1f********** * * * * * *** * * * *** ** Fees, * *, * * * * * * * * * * * ** * * * * * * * * * * * *** * * *** * * *** **
Submittal Fee $ Permit Fee $ D
Notary $
Scanning $
Double Fee $
Structural Review. $ Total Fee Now Due $ -5l8'0
Training/Education Fee $
Radon $
CCF $ CO /CC $
DPBR $
Violation date:
Technology Fee $
Bond $
See Reverse side -*
Bonding Company's Name (if applicable) 2
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 afier 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 f 2 2 A)
Owner or Agent
The foregoing instrument was acknowledged before me this lg
day of go" , 200 , by (I Soa 1tr't -)1 a% ® 64
who is personally known to me or who has produced t •
(-°l1r-^°1JC As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
OdLa'n
My Commission Expires:
AWiti t+TERESA J SOLOMON
:at:';
i *: *' MY COMMISSION # EE131935
?ta H. EXPIRES November 08, 2015
�.
(407) 395.0163 Fto tdallotarySenvice.com
* * * * * * * * * * * * * * * * * * * * * * * * * * **
APPROVED BY
/0
Signature 4- SQ-J1C2 Al----
(
Contractor
The foreg ing in trument was ackno led •.ed bef.i
day of , 20)1 , by LJL��
who is personally known tto me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commissi
CLAUDIA V. CUBILLOS
My Comm. Expires Sep 23, 2015
'" fe Commission • EE 128810
''',8 i .10 Bonded Through National Notary Assn.
* *ok**rot9eRak°kdr4r°kakaY*iY*** k9r9r* t***9rnY4rsF* *aY**** vkoY+ t9r9eakvYot***3r**dr +k** *°Y*°Y***** Ar****4t3kik°Y***
//
Plans Examiner
Engineer
(Revised 07 /10 /07)(Revised 06/10/2009)
Zoning
Clerk checked
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Lisa Rabah
PERMIT #: 13-SC-1379875
APPLICATION 0: AP 1053490
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR859903
PROPERTY ADDRESS: 69 NW 99 St Miami, FL 33150
LOT: 18
BLOCK: 5 SUBDIVISION:
PROPERTY ID #: 11- 3101- 018 -0490
(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 1 GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K ( ] GALLONS DOSING TANK CAPACITY ( ]GALLONS @( ]DOSES PER 24 HRS #Pumps [ ]
D [ 150 ] SQUARE FEET SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [s] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: F.F.E.: 13.07' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 19.401 (J INCHES 1' FT ][ ABOVE 4 BELOW BENCHMARK/ REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 49.40 ] [I INCHES Y FT 1 [ ABOVE 4 BELOW b BENCHMARK /REFERENCE POINT
L
D FILL REQUIRED:
( 0.001 INCHES EXCAVATION REQUIRED: I 30.00] INCHES
1— Install 900 gat. category-3 septic tank equipped with an approved filter. 2 -The licensed contractor installing the
O system is responsible for installing the minimum category of tank in accordance with sec. 64E- 6.013(3)(f). 3- Install 150 sf
T of drainfield in trench configuration. 4- Perimeter of excavation area shall be at least 2 ft wider and longer than the
H proposed absorption trench. 5- Invert elevation of drainfield to be no less than 9.45' NGVD. 6. Bottom of drainfield 7 elevation to be no less than8.95' NGVD.
E THIS PERMIT IS NOT FOR ADDIT ., : (s). REPAIR Alt
R X E t
,yip
SPECIFICATIONS B ` r e contractor (BaY i r eP.) iv `pq;:ired to perform a
aioaceitt to the tir7c °anl0 evcauatinn at tha
APPROVED Y": TITLiime of final Inspection. Poor ti; Final Approval, the DOH Dade
Pedro Ospina Ina
DATE ISS D: 11/28/2011 results to the original site evaluation 1 r DATE: 02/26/2012
roinepeotlon fee will be assessed if tha cnn ra ors n
DH 4016, 08/09 (Obsoletes all previous editionsatve ttg8lariaAQa�t�a1B.
Incorporated: 64E- 6.003, FAC
v 1. 1.4
CHD
AP1053490
SE856837
Page 1 of 3
• •
STATE OF FLORIDA
DEPARTMENT OF HEALTH •
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
•
PART II =' ITE PLAN-
Scale: Each block represents 5 feet and 1 inch = 50 feet.
•
•
r•
' i- •• � •
;• iLit -:-4....1..1 {..l i ! : 1 !" r! il......'_� i_t_i__.;... !_. :i- _�_(._i_ _:_:_'i •
P
i ! t '{ {.. !_.l...L ...i _ I
�_ t '77 �} ii. ! �t ^. 11 t i I
L i i'.,...,„___. ». .._..._! i--1_ •...i_..]_ • ; '_. i...S_' - i _.i.- ,.f_.J•_ . !� i - -'•_I .3_1 _i..1_ .. _ t !
Raba Io - G9 Nvo c01 c+ MShores 331S0
t 717-t -.t
Notes:
�.� • mb a s' i C t' k.
•
F c a-t^ N c ) GJcIk -r h e G n�
N-en,J 15o Si P}-
Site Plan submitted by:
Plan Approved
By
i
1
con
Tide
ate
Co my 1 alth Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
C)}44015, 10/96 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744- 002 - 4015.6)
Page 2 of 3