PL-11-1116Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
10—ADP
Inspection Number: INSP- 171745 Permit Number: PL -6 -11 -1116
Scheduled Inspection Date: April 25, 2012
Inspector: Hernandez, Rafael
Owner: SMART, DARIK & MARLENIS
Job Address: 540 GRAND CONCOURSE
Miami Shores, FL 33138-
Project: <NONE>
Contractor: HOME OWNER
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number (305)751 -8127
Parcel Number 1132060171411
Building Department Comments
REPLACE SEPTIC TANK DRAINFIELD
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- 161126. PLEASE MAKE SURE
SIDEWALKS ARE REPAIRED BEFORE FINAL INPSECTION IS
APPROVED. THANKS
hrs in file broken sidewalk
April 25, 2012
For Inspections please call: (305)762 -4949
Page 10 of 24
BUILDING
PE
FBC
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
• Permit No.
PPLICATION Master Permit No.
?Li - wto
Permit' e: PLUMBING 7
OWNER: Name (Fee Simnle Titleholder)T %t i _�1 Phone#: [ 5 / �( -?
Address: 6 Cam/ �� Groco.irge
State: FC Zip: 3 3 ( 3 Z5
Phone#:
City: NI 1 I Ct i*t l . k∎cre S
Tenant/Lessee Name:
Email: e rr1av -3'\ tot L i e04,V l St NBC'
JOB ADDRESS: J I C..f.Ce
City:
Miami Shores County: Miami Dade Zip: 33 13
Folio/Parcel #:
Is the Building Historically Designated: Yes NO Flood Zone: A-3 C)
CONTRACTOR: Company Name: Phone#:
Address:
City: State: Zip:
Qualifier Name: Phone#:
State Certification or Registration #: Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace
Description of Work:
❑Demolition
CO\TIO&oi&xC.
* * * * * * * * **
** ******* ** ** * * * ** *** * * ***** Fees************* * ****** * *** * * ** * ** ***** ** ** * * **
Submittal Fee $ d 4 Permit Fee $ CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
$ Training/Education Fee $ Technology Fee $
Structural Review $
wawe6 )6 .
TOTAL FEE NOW DUE $_22322.
4
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 F.I.ECTRICAL 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 approv:d and a reinsge.ofiarrjeeed.
Signature Jrion■
Signature
Owner or Agent Contractor
t
The foregoing instrument was acknowledged before me this I� The foregoing instrument was acknowledged before me this
day of PI A.ro; X1.0 1Z1 by Drta 3tYt 64;1 , day of , 20 _, by
who is personally known to me or who has produced 9 who is personally known to me or who has produced
As identification and who did take an oath. as identification and who did take an oath.
NOTARY PUBLIC:
\ \ \ \ \UIIIII f Ii ///
cVSI 1/1,
,/ DSIL► 6
Sign: r *z".47
:
PUBIIC _
Print: _ Print:
Commission .'
My Commission Expires: Nom'' . EE 173059 My Commission Expires:
***************************************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
NOTARY PUBLIC:
APPROVED BY Plans Examiner Zoning
Structural Review Clerk
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OWNER BUILDER DISCLOSURE STATEMENT
NAME. `OV-- t ` DATE: 3h')-//
ADDRESS: K0 GM(Pd._ CCA-C A4 wt( S(c,r Pe- 3313k- -
Do hereby petition the Village of Miami Shores to act as my own contractor pursuant to the laws of the State of Florida, F.S 489.103(7).
And I have read and understood the following disclosure statement, which entitles me to work as my own contractor; I further
understand that I as the owner must appear in person to complete all applications.
State Law requires construction to be done by a licensed contractor. You have applied for a permit under an exception to the law. The
exemption allows you, as the owner of your property, to act as your own contractor even though you do not have a license. You must
supervise the construction yourself. You may build or improve a one - family or two- family residence. You may also build or improve a
commercial building at a cost of $25,000.00 or less (The new form states 75,000). The building must be for your own use and
occupancy. It may not be built for sale or lease. If you sell or lease a building you have built yourself within one year after the
construction is complete, the law will presume that you built for sale or lease, which is a violation of this exemption. You may not hire
an unlicensed person as a contractor. It is your responsibility to make sure the people employed by you have licenses required by state
law and by county or municipal licensing ordinances. Any person working on your building who is not licensed must work under your
supervision and must be employed by you, which means that you must deduct F.I.C.A and with- holdings tax and provide workers'
compensation for that employee, all as prescribed by law. Your construction must comply with all applicable laws, ordinances,
buildings codes and zoning regulations.
Please read and initial each paragraph.
1. I understand that state law requires construction to be done by a licensed contractor and have applied for an owner - builder
permit under an exemption from the law. The exemption specifies that I, as the owner of the property listed, may act as my o
contractor with certain restrictions even though I do not have a license.
Initial
2. I understand that building permits are not required to be signed by a property owner unless he or she is responsible for the
construction and is not hiring a licensed contractor to assume responsibility.
Initial
3. I understand that, as an owner builder, I am the responsible party of record on a permit. I understand that I may protect myself
from potential financial risk by hiring a licensed contractor and having the permit filed in his or her name instead of my own
name. I also understand that the contractor is required by law to be licensed in Florida and to list his or license on
permits and contracts. '`�'
Initial ,�
4. I understand that I may build or improve a one family or two-family residence or a farm outbuilding. I may also build or improve
a commercial building if the costs do not exceed $75,000. The building or residence must be for my use or occupancy. It may
not be built or substantially improved for sale or lease. If a building or residence that I have built or substantially improved
myself is sold or leased within 1 year after the construction is complete, the law will presume that I built tially
improved it for sale or lease, which violates the exemption.
5. I understand that, as the owner - builder, I must provide direct, onsite supervision of the construction.
Initial
Initial
6. I understand that I may not hire an unlicensed person to act as my contractor or to supervise persons working on my building or
residence. It is my responsibility to ensure that the persons whom I employ have the license required by law and by county or
municipal ordinance.
7. I understand that it is frequent practices of unlicensed persons to have the property owner obtain an owner- builder permit that
erroneously implies that the property owner is providing his or her own labor and materials. I, as an owner- builder, may be held
liable and subjected to serious financial risk for any injuries sustained by an unlicensed person or his or employees while
working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an
owner - builder and am aware of the limits of my insurance coverage for injuries to workers on my props
Initial
8. I understand that I may not delegate the responsibility for supervising work to be a licensed contractor who is not licenses to
perform the work being done. Any person working on my building who is not licensed must work under my direct supervision
and must be employed by me, which means that I must comply with laws requiring the withholding of federal income tax and
social security contributions under the Federal Insurance Contributions Act (FICA) and must provide workers compensation for
the employee. I understand that my failure to follow these may subject to serious financial risk.
Initial
9. I agree that, as the party legally and financially responsible for this proposed Construction activity, I will abide by all ap
laws and requirement that govem owner - builders as well as employers. I also understand that the
Construction must comply with all applicable laws, ordinances, building codes, and zoning regulations.
livable
Initial
10. I understand that I may obtain more information regarding my obligations as an employer from the Internal Revenue Service, the
United States Small Business Administration, and the Florida Department of Revenues. I also understand that I may contact the
Florida Construction Industry Licensing Board at 850.487.1395 or htt .: / /www.m oridalicense.com /db.r /.ro /c
11. I am aware of, and consent to; an owner- builder building permit applied for in my name and understands that I am the party
legally and financially responsible for the proposed construction activity at the following address:
vi • I,
12. I agree to notify Miami Shores Village immediately of any additions, deletions, or changes to any of the inform
have provided on this disclosure.
Initial
Licensed contractors are regulated by laws designed to protect the public. If you contract with a person who does not have a
license, the Constr4uction Industry Licensing Board and Department of Business and Professional Regulation may be unable to
assist you with any financial loss that you sustain as a result of contractor may be in civil court. It is also important for you to
understand that, if an unlicensed contractor or employee of an individual or firm is injured while working on your property, you may
be held liable for damages. If you obtain an owner - builder permit and wish to hire a licensed contractor, you will be responsible for
verifying whether the contractor is properly licensed and the status of the contractors workers compensation coverage.
Before a building permit can be issued, this disclosure statement must be completed and signed by the property owner and
retumed to the local permitting agency responsible for issuing the permit. A copy of the property owner's driver license, the
notarized signature of the property owner, or other type of verification acceptable to the local permitting agency is required when
the permit is issued. y�
Was acknowledged before me this d U day of tin `ini (..k„ 20 12-
By CeAdg--) who
me or who has
Produced there License or as identificatio
OWNER
4
NOTAR
1PH.;:tr" 9„ CLAUDIA V. CUBILLOS
Pv4 .
INNotary Public - State of Florida
My Comm. Expires Sep 23, 2015
°s , ,,, BondeCommission hrough National Notary Assn.
1
March 12, 2012
State Wide Septic Connections
Teresa Solomon
6032 SW 23rd Street
Miramar, FL 33023
RE: 540 Grand Concourse
Miami Shores, FL 33138
Teresa,
Please be advised that the intent of this letter is to inform you that you will no longer be the
contractor on record for the property located at 540 Grand Concourse Miami Shores, FL 33138. Thank
you for your time and cooperation concerning this matter.
Regards,
Darik Smart
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICANT: Dank Smart
APPLICATION
PERMIT #: 13-SC-1080354
DOCUMENT #:F1837510
DATE PAID: 06/29/2011
FEE pi m70.00
RECEIPT #:13 -PID- 1661530
AGENT: Statewide Septic
PROPERTY ADDRESS:
LOT: 3, 4, 5
SUBDIVISION:
540 Grand Concorse El Portal, FL 33138
Miami Shores, Section 4
BLOCK:
ID# : 11- 3206 -017 -1411
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION
[01]
[02]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
TANK SIZE [1] 1200.00 [2]
TANK MATERIAL
OUTLET DEVICE
MULTI- CHAMBERED [r Y V N ]
OUTLET FILTER Tuf -Tite
Concrete
LEGEND 1. 13- 076 -12DC3
WATERTIGHT
LEVEL
DEPTH TO LID
DRAINFIELD INSTALLATION
2.
[10] AREA [1] 675 [2] SOFT
[11] DISTRIBUTION BOX HEADER X
[12] NUMBER OF DRAINLINES 1. 5.00 2.
[13] DRAINLINE SEPARATION
[14] DRAINLINE SLOPE
[15] DEPTH OF COVER
[16] ELEVATION [ ABOVE /
[17] SYSTEM LOCATION
[18] DOSING PUMPS
[19] AGGREGATE SIZE
[20] AGGREGATE EXCESSIVE FINES
[21] AGGREGATE DEPTH
BELOW
ISM 50.64
FILL
[22]
[23]
[24]
[25]
[26]
Comments:
/ EXCAVATION MATERIAL
FILL AMOUNT
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEMENT MATERIAL
SETBACKS
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
SURFACE WATER
DITCHES
PRIVATE WELLS
PUBLIC WELLS
IRRIGATION WELLS
POTABLE WATER
65
BUILDING FOUNDATIONS
PROPERTY LINES
OTHER
FILLED / MOUND SYSTEM
[36]
[37]
[38]
[39]
5
DRAINFIELD COVER
SHOULDERS
SLOPES
STABILIZATION
ADDITIONAL INFORMATION
FT
FT
FT
FT
FT
FT
FT
FT
FT
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTOR Teresa,J Solomon (Statewide
[48] OTHER ADS ARC 24
ABANDONMENT
[49] TANK PUMPED 06M2011
[50] TANK CRUSHED & FILLED 06/30/2011
CONSTRUCTION [
FINAL SYSTEM [
APPROVED
APPROVED
DISAPPROVED 3:
/ DISAPPROVED ]:
(Explanation of Violations on following page)
Dade CHD DATE: 06/30/2011
Ronald E Cave (Dade County Environmental Health)
Dade CHD DATE: 06/30/2011
Ronald E Cave (Dade County Environmental Health)
DH 4016, 08/09 (Obsoletes all previous editions
Incorporated: 64E- 6.003, FAC
which may
not be used)
Page 2 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICATION #:
PERMIT #: 13-SC-1080354
DOCUMENT #:F1837510
DATE PAID: 06/29/2011
FEE PAID:7O.0 0
RECEIPT #:13 -PID- 1661530
Violation Number
Comment
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
Page 2 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICANT: Darik Smart
AGENT: Statewide Septic
PROPERTY ADDRESS: 540 Grand Concorse El Portal, FL 33138
LOT: 3 , 5
SUBDIVISION:
APPLICATION #: AP943593
PERMIT #: 13-SC-1080354
DOCUMENT # : F1837510
DATE PAID:06/29/2011
FEE PAID:70.00
RECEIPT #:13 -PID- 1661530
Miami Shores, Section 4
BLOCK:
ID#: 114206-017-1411
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION
[01]
[02]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
TANK SIZE [1]
TANK MATERIAL
OUTLET DEVICE
1200.00 [2]
Concrete
MULTI- CHAMBERED [) Y / N ]
OUTLET FILTER Tuf -Tite
LEGEND 1. 13- 076 -12DC3 2.
WATERTIGHT
LEVEL
DEPTH TO LID
DRAINFIELD INSTALLATION
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
FILL
[22]
[23]
[24]
[25]
[26]
Comments:
AREA [1] 675
DISTRIBUTION BOX
NUMBER OF DRAINLINES
DRAINLINE SEPARATION
DRAINLINE SLOPE
DEPTH OF COVER
ELEVATION [ ABOVE
SYSTEM LOCATION
DOSING PUMPS
AGGREGATE SIZE
AGGREGATE EXCESSIVE FINES
AGGREGATE DEPTH
[2]
SQFT
HEADER X
1. 5.00 2.
BELOW
] sM 50.64
/ EXCAVATION MATERIAL
FILL AMOUNT
FILL TEXTURE
EXCAVATION DEPTH
AREA REPLACED
REPLACEMENT MATERIAL
SETBACKS
[27] SURFACE WATER
[28] DITCHES
[29] PRIVATE WELLS
[30] PUBLIC WELLS
[31] IRRIGATION WELLS
[32] POTABLE WATER
[33] BUILDING FOUNDATIONS
[34] PROPERTY. LINES
[35] OTHER
FILLED / MOUND SYSTEM
[36]
[37]
[38]
[39]
DRAINFIELD COVER
SHOULDERS
SLOPES
STABILIZATION
65
FT
FT
FT
FT
FT
FT
5 FT
FT
FT
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTOR Teresa :J Solomon (Statewide
[48] OTHER • ADS ARC 24
ABANDONMENT
[49] TANK PUMPED 06/30/2011
[50] TANK CRUSHED & FIT,T.Fn 06/30/2011
CONSTRUCTION [
FINAL SYSTEM [
APPROVED
APPROVED
DISAPPROVED ]'
/ DISAPPROVED 3:
(Explanation of Violations on following page)
DH 4016, 08/09 (Obsoletes all previous
Incorporated: 64E- 6.003, FAC
EH Database v10.1
Dade CHD DATE: 06/30/2011
Ronald E Cave (Dade County Environmental Health)
Ronald E Cave (Dade County Environmental health)
editions which may not be used)
AP943593
Dade CHD DATE: 06/30/2011
EID1000354
Page 2 of 3
a
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICATION #: AP 343593
PERMIT #: 13-SC-1080354
DQcNT #:F1837510
DATE PAID:06/29/2011
FEE PAID:7O.00
RECEIPT #:13 -PID- 1661530
Violation Number
Comment
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
EH Database v 1.0.1
AP943593
EID1080354
Page 2 of 3
°P1 11--111G2
Miami Shores Village
rid s��
1 % Building Department
`lam' f��� ' 10050 N.E.2nd Avenue, Miami Shores, Florida 3313
,/ r°j ik Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING
PERMIT APPLICATION
FBC 200$
Permit Type: Plumbing
Owner's Name (Fee Si
Owner's Address
Per rr it No
Master Per it No.
nple Titleholder) DCuri 4- Motel eniS greh,44Phone #
540 Cirartel fie o,,rse
City r S rtS
Tenant/Lessee Name
E -MAIL:
Job Address (where the work is being done)
City Miami hores Village
L JUN 2 02011
k\- \\LD
State Fz, Zip 33 i 3s-
Phone #
59-0 6rc Covco u
FOLIO / PARCEL #
County Miami -Dade Zip 33 33c59
i 1 m 0 (°7- t 1-1-1
Is Building Ristoricall ! Designated YES NO X
Contractor's Company Name S'G+e LJ (dCI 1 c CPI iP'"s Phone #
Contractor's Address 3 S9 O S - Rd -70-2_6-
City M `rte State li,,
Qualifier Name 1 -eretc pryva --
6'61 -6&
Zip J3i92 3
Phone #
State Certificate or Registration No. t'S q -11? 6 Z Certificate of Competency
E -MAIL:
Architect/Engineer's N tme (if applicable) Phone #
Value of Work For this Permit $ 6600
Type of Work:
Describe Work:
['Addition
]Alteration
Square / Linear Footage 0
['New
No.
Work: 02 5
r /Replace ❑ Demolition
***** * * * *** * ****** *** *,* *** * *** * **,* *****Fees * * * * * * *** * * *** *** ** * **
Submittal Fee $ ✓`-` Permit Fee $ 3 00 -- CCF $
Notary $ Train' g /Education Fee $ Technology
Scanning $ Radon $ DPBR $
Bond $ Code Enforcement $
Structural Review. $
*WWcwW *xxxrxxxxx * * * **
CO /CC
Fee $
ning $
Total Fee Now D
$
See Reverse side
r
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
State Zip
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.
Signature
Owner or Agent
The foregoing instrument was acknowledged before me this j.o
day of i jrQ, 20 I , by Do r i .S ,
who is personally known to me or who has produced Dt p�
4 a x'41 As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expire
snaeaaea®a ® ®aaa ® ®ae®a
Signature
Contractor
The foregoing instrument was acknowledged before me this
day of P ..,., 20 i, by a,f ,�`
who is personally known to me or who has produced 14—
as identification and who 4}q take an oath.
��``N.vlera Ilutt� * *,/
°,
NOTARY PUBLI
Sign:
Print:
My Commission Expires:
��''®®����±±pp ®n^aaaaaeua�q!!l9N���
oYxxxxxxxxxxx+kxxx*.4. Y.xxiit^&�kSLytZlw lls * ****xx**xx*x***xx* ***. xxxx**x**xxxxx
' YI m# Gg m DD0733346 13
: �, fires 11/8/2011 =
APPLICATION A.PPRIV `� FioridaWan/Assn,� ii
madame 4a4444444444 4gaaoaaa emau44444mi
(Revised 02/08/06)
,'r
/2/
a:x***.a4,,,p: Yk Ydc ii �r`4xa\xxx
� / /I /llllllll
Plans Examiner
Engineer
Zoning
06/20/11 02:O1PM
STATEWIDE SEPTIC CONNECTIONS INC 9549630085 p.01
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS New
APPLICANT: Dee rik Smart
PERMIT # :13 -SC- 1080354
APPLICATION #: AP943593
DATE PAID:
FEE PAID:.
RECEIPT #:.
DOCUMENT #: PR794529
PROPERTY ADDRESS: 540 Grand Concorse Miami, FL 33138
LOT: 3 +4 +5
BLOCK: SUBDIVISION: Miami Shores, Section 4
PROPERTY ID #: 11- 3206 -017 -1411
(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
MATERIAL FACTS,
TO MODIFY THE
NULL AND VOID.
OTHER FEDERAL,
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.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1,200 ] GALLONS / GPD Septic Tank CAPACITY
A [ ] GALLONS / GPD N/A CAPACITY
N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK :1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS 0[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 625 ] SQUARE FEET Trench configuration SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM; (x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATICN: (x] TRENCH ( ] BED [ ]
N
F LOCATION OF BENCHMARK: FEE........ 12.42' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 29.003 ti INCHES FT ][ ABOVE AELOW BENCHMARK /REFERENCE
E BOTTOM OF DRAINFIELD TO BE [ 59.00 ] INCHES f FT 3 [ ABOVE LAW 3 BENCHMARK/REFERENCE
L
D FILL REQUIRED: [ 0.00] INCHES
EXCAVATION REQUIRED: [ 72.003 INCHES
POINT
POINT
• 1.- Install 120() gal. category-3 septic tank equipped with an approved filter.
2 -The licenced contractor is responsible for installing the minimum category of tank sec. 64E- 6.013(3)(t).
T 3.- Install 625 sf of drainfield in TRENCH configuration.
H 4.- Install 42" c f slightly limited soil at the bottom of the drainfield.
5.- Perimiter al excavation area shall be at least 2 ft wider and longer than the proposed absorption bed.
E
6.-Invert elevation of drainfield to be no Tess than 8.00 ft NGVD.
R 7.- Bottom of crainfield elevation to be no less than 7.50 ft NGVD.
SPECIFICATION: BY:
Gerard L Philtre
APPROVED BY: Al
Jo -eph�.
DATE ISSUED: 12/ r %v 4
TITLE:
TI ngi eer Specialist II
Dade CHD
EXPIRATION DATE: 06/30/2011
DH 4016, 10/9" (Previ , Editions May Be Used) Page 1 of 3
v 1.1.4
AP943593 SE804032