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PL-12-38Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP - 168584 Permit Number: PL- 1 -12 -38 Scheduled Inspection Date: January 27, 2012 Inspector: Hernandez, Rafael Owner: RUSSELL, PHYLLIS Job Address: 1061 NE 91 Terrace Miami Shores, FL 33138- Project: <NONE> Contractor: STATEWIDE SEPTIC CONNECTIONS Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1132050010070 Phone: (954)963 -0082 Building Department Comments REPLACE BROKEN SEPTIC TANK & 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 January 26, 2012 For Inspections please call: (305)762 -4949 Page 8 of 17 K7 v,f1: 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 JAN 1 a 1 2 ) Permit No.P. t Z -.3'46° Master Permit No. Permit Type: PLUMBING OWNER: Name U� ' DC C zi C Le e Phone#: " 12‘p- 1Cj i 1 (Fee Simple Titleholder): WI �� (�'�� `� Address: 1 C co V nu ° E'(n T f City: f° \i Ci r :Sh ✓a,� .,) State: C t Zip: 1' K, Tenant/Lessee Name: Phone #: Email: JOB ADDRESS: t �� 'Tea. - City: Miami Shores County: Miami Dade Zip: Folio/Parcel #: H w ic d Is the Building Historically Designated: Yes CONTRACTOR: Company Name: ..74 -^ Address: PO 4r" r ' City: J ° ' r CCJ Qualifier Name: eirt- ttf NO Flood Zone: Phone #:76 d State: Phone #: State Certification or Registration #: Certificate of Competency #: Contact Phone #: Email Address: DESIGNER: Architect/Engineer: Phone #: Value of Work for this Permit: $ 24-c Square/Linear Footage of Work: - r? Type of Work: °Address °Alteration UNew ,FRepair/Replace Description of Work: el 4 , (< �� /I fi qy..°�, qi 1t) ^e9 °Demolition T., c(d ****+ x* ********+ x******** **************** Fees********* ****+ x**+ x****************** ****+x**** Submittal Fee $ Permit Fee $ .5 ®U 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' 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. Signatur Owner or Agent The foregoing instrument was acknowledged before me this S day of , :Ac ,20‘ 2-,by 44ihU Lace who is personally known to me or who has produced Dr °'k9 As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: EIESA J SOLOMON Signature The foregoing instrument was acknowledged before me this day of , 20 _, by who is personally known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: My Commission Expires: APPROVED BY ON # EE131935 oP `t EXPIRES November 08, 2015 (407) 306.0153 FloridallotaryService.com /1- f. Plans Examiner (Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09) Sign: Print: My Commission Expires: Zoning Structural Review Clerk STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: William Lee PERMIT #:13 -SC- 1385648 APPLICATION #:API057187 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT #:PR863362 PROPERTY ADDRESS: 1061 NE 91 Ter Miami, FL 33138 LOT: 8 BLOCK: 1 SUBDIVISION: PROPERTY ID #: 11- 3205 -001 -0070 [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 SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. NOT GUARANTEE MATERIAL FACTS, TO MODIFY THE NULL AND VOID. OTHER FEDERAL, SYSTEM DESIGN AND SPECIFICATIONS T [ A [ N [ K [ D A I N F I E L D 0 T H R 1,200 ] GALLONS / GPD Septic 0 ] GALLONS / GPD 0 ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY [ 400 ] SQUARE [ 0 ] SQUARE TYPE SYSTEM: CONFIGURATION: FEET FEET [x] STANDARD [ ] TRENCH CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] SYSTEM SYSTEM [ ] FILLED [ ] MOUND [x] BED [ ] LOCATION OF BENCHMARK: FFE: 10.90' NGVD ELEVATION OF PROPOSED SYSTEM SITE [ 10.60 ] [I INCHES I FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE BOTTOM OF DRAINFIELD TO BE [ 33.60 ] [I INCHES I FT ] [ ABOVE BELOW I BENCHMARK /REFERENCE FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 30.00 ] INCHES POINT POINT - Install 1200 g septic tank. - Install 400 sq ft drainfield. - Elevation of bottom of drainfield to be no Tess than 8.10' NGVD. - Water lines to use sch/40 pipes or to be sleeved within 10 ft of system. - 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 not at the jobsite at the arranged time. SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: Teresa J Sol Jos 01/ _'x/2012 DH 4016, 08/09 (Obsole Incorporated: 64E -6.0 TITLE: Master Septic Tank Contractor r gineer Specialist II Dade s all previous editions which may not be used) 3, FAC v 1.1.4 AP1057187 EXPIRATION DATE: 04/09/2012 SE859786 cim Page 1 of 3 STATE OF FLORIDA DEPARTMENT OF HEALTH HON FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT Permit Application Number PART 1I - .SITEPLAN Scale: Each block repr sent 10 feet and 1 inch = 40 feet. ■■■■■■I■■■HaU..U.■■ ■■■■U■■■■■ MEMEMMEMMAREMMEMINMEMEMEMMEMEMM ■ ■■■■■ •H• ■ .! •iii Nl11I■ ■■ ■` NM � L ■ ■ ■■■■■■■■■i■■■■ ■ ■ ■ ■■ ■ ■ ■ ■■ ■■■ ■■ ■ ■■■ ■■■ ■ ■I■■■■ ■ ■ ■ ■ ■■■ ■■■■■ ■■■■ °■ ■ ■ ■ ■'M■ ■ ■ ■■■■■■■ ■■ ■ ■ ■ ■ ■ ■■ ■ ■i ■ ■ ■i iii } ■ ■■■■ ■■ ■ ■ ■ ■■ ii ■■ ■ uL. n ■ 'H• ■ ■■ ■ ■ ■ ■ ■ ■ ■ ■■ ■■ . • ■ ■■ ■ ■■i ■■■,■w■ ■ ■ ■■m11■■■ ■ ■ ■ ■■ ■■ ■ ,, , ■■ ■■■ ■;UI1■ ■ ■■Milli■■■ ■■ ■■ ■■■ EC I EM ■ ■ ■ ■ ■■ UHEM■■■ ■ ■ ■ ■ ■ ■■ flIfliflHhII1AI!JiUUHiIIU ■■■■ ■ ■■■ ■ ■ ■■ U ■ ■ ■ ►��, ■■ ■ ■� ■■ ■ ■■ ■■ ■ ■ ■■■■■■■■M■ ■■■ ■■■■■ ■M ■i■■■■ ■■ ■■■■I■ ■ ■E ■!1■ ■ ■■ ■ ■ ■!■■■■■■■■■■■ Notes: �e k C, ri Site Plan submitted by( ture Plan Approved_ By Not Approved ALL C rth1`a Title Date County Health Department ANtES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015, 10/96 (Replaces HR -H Form 4016 which may be used) (Stock Number 5744- 002 - 4015 -6) Page 2 of 4