PL-11-427Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 157118 Permit Number: PL- 3- 11-427
Inspection Date: August 08, 2012
Inspector: Hernandez, Rafael
Owner: ROBERGE, KERRY & GASTON
Job Address: 100 NE 92 Street
Miami Shores, FL
Project <NONE>
Contractor: JOE LEWIS SPECIALTY SEPTIC
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060133290
Phone: (305)662 -7979
Building Department Comments
TANK & DRAINFIELD
Passed
Inspector Comments
HRS IN FILE - 07/26/2012
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled
re- inspection fee is paid.
until
August 08, 2012
For Inspections please call: (305)762 -4949
Page 1 of 1
APPROVED 1
j APPROVED 1
11 -'12�-
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITEE SHWA E TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
A'ePumnuT: Richard Cajnes
AGENT: Joe Lewis Specialty
PROPERTY ADDRESS!
LOT 13 &: 14
3i1BDIVISION:
APPLICATION #:AP996883
PERMIT #;13- SC- 1305774
DOCDMENT #;FI825346
DATE w.ID:03/08/2011
rEE PAlpt200.00
RECEIPT 4i:13 -PID- 1571037
100 NE 92 St Miami, FL 33138
Miami Shores
BLOCK; 24
IDO: 11 -3206- 013.3290
CHECKED [X] ZTEMs ARE NoT IN COMPLIANCE WITH STATUTE OR R1QLE AND MUST BE CORRECTED.
1
1
1
3
3
3
1
1
3
]
1
1
3
TANK INSTALLATION
[01]
[02.3
[03]
[041
[051
106]
107]
[093
[09]
TANK SIZE [3-]
TANK MATERIAL
OUTLET DEVICE
MULTI- CHAMBERED
OUTLET FILTER
900.00 [2]
Concrete
[1 / N 1
Polylok
LEGEND 1. 13- 076 -04DC3 2.
WATERTIGET
LEVEL
DEPTH TO LID
DRAINFIELD INSTALLATION
[10]
[111
[123
[13]
[143
[151
[163
[3.7]
[181
[191
[20]
[231
FILL
[22]
[231
[24]
[25]
[261
comments:
AREA [1] 225
DISTRIBt7TION SOX
NaKREE OF DRAINLINES
DRATNLINE SEPARATION
DRAINLINE SLOPE
DEPTH OF COVER
ELEVATION [ ABOVE /
SYSTEM LOCATION
DOSING PUMPS
AGGREGATE SIZE
AGGREGATE EXCESSIVE FINES
XcGREGATE DEPTH
[2]
SjQFT
_ HEADT4R X
1. 3,QQ 2.
IBELOW
/ EXCAVATION MATERIAL
FILL AMOUNT
>'I i. TEXTURE
EXCAVATION DE£'T$
AREA REPLACED
REPLACEMENT MATERIAL
SETBACKS
] [27] SURFACE WATER
1 [28] DITCHES
1 [29] PRIVATE WELLS
3 [30] PUBLIC WELLS
] [31] IRRICATIOi4 WELLS
1 132] POTABLE WATER
3 [331 BUILDING FOUNDATIONS
1 [34] PROPERTY LINES
] [35] OTHER
1
3 [36]
[373
[38]
1
FILLET / MOUND SYSTEM
[391
10
3
FT
FT
FT
FT
FT
FT
5 FT
FT
FT
DRA.3i1FIELD COVER
SHOULDERS
SLons
STABILIZATION
.ADDITIONAL INFORMATION
] [401 7NOs$TRUCTED AREA
1 [41] STORM WATER RUNOFF
] [421 ATA XINE
1 [43] I.1AINTELWWZ AGREEMENT
] [441 BUILDI O AREA
] [451 LOCATION CONFORMS WITH SITE PLAN
3 [463 FINAL SITE GRADING
3 [47] CONTRACTOR
3 148] OTHER
ABANDONMENT
[ 1 [493 TARR PUMPED 03/18/2011
[ 3 [50] TANK CRUSHED & FITLrn
03118/2011
C.ONSTsocvxos l:
FINAL SYSTEM
[
/ Dade
DISAPPROVED 1:
/ DISAPPROVED ]i
(Explanation of Vi oXatl.ose oA following pago)
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated; 64E- 6.003, FAC
EH Database v 1.0.1
Ronald E Cava (Dada County Environmental Health)
Ronald E Cave (bade County Environmental Ilea
AP996883
CHU DATE: 03/18/2011
Dade cHD DAME! 03/18/2011
EIDrt3D5774
Page 2 of 3
BUILDING
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. R_44 1
PERMIT APPLICATION Master Permit. No.
FBC 20
Permit Type: PLUMBING 6A59.71 r
OWNER: Name (Fee Simple Titleholder): 7Z>1 P-vher Phone #: �S �S " 2c3— �'�i� %
Address: /AO , _ %rv�it _ X/
City: �/J,� L . S7,m�es
C6aD
State: / -
Zip: 33/3ce.
Tenant/Lessee Name: Phone#:
Email: C : - , _S re) l
JOB ADDRESS: /00 Ai. 0 472- N, sr
City: Miami Shores
County:
Miami Dade
Zip: g3 3tgo
Folio/Parcel #:
Is the Building Historically Designated: Yes
NO Flood Zone:
CONTRACTOR: Company Name: JO � ,d.( r
Address: ) O 75 s4.-' X/ 4 vL
City: 011 State: 6= (
Qualifier Name: P Lit— J j
Phone #:
^Zi3 -/72J
Phone #:
Zip: 7307 3
State Certification or Registration #: Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone #:
Value of Work for this Permit: $ Z / Z 0 0 Square/Linear Footage of Work:
Type of Work: ❑Address ❑Alteration ❑New ❑Repair/Replace
Description of Work:
2-6 CJ sI Fr'
❑Demolition
*** *************** ***:x **+x**+x**+x ******** Fees**** *** *: x*+ xm+ x******** ** * * ***+x *+x+x******* *****
Submittal Fee " 0 • it ..?°° Permit Fee $ �� .---- 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 1,
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. 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
day of , 20 LL by 10�1°1 , 1 ee,
who is personally known to me or who has produced
As identification and who did take an oath.
NOTARY PUBLIC:
Sign: 'e
Print: 1 n (� f9 to
My Commission Expires:
001111111111111��\
APPROVED BY , "/ 3 / Plans Examiner
Signature
Contractor
The foregoing instrument was acknowledged before me this F
day of , 20 W, by
who is personally known to me or who has produced
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
ti41�1tII11111 //j1,
.\``0r1S Sli
rL(,
r/ /JfO✓
OVARY PUBLIC
Commission #
�u'�9•.DDi6S909.�'@•��:
" //// F‘..0,,,\\•
,, ,
4�x�x***** �x�x�x�x�x**** �x�u*+ x�x�x�x�xa�x��x **** *** *�x:x�x�x�x� *441+l A�#�kliz ** **
Structural Review
(Revised 07 /10 /07)(Revised 06 /10 /2009)(Revised 3/15/09)
Zoning
Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Richard Caines
PERMIT # :13 -SC- 1305774
APPLICATION #: AP996883
DATE PAID:
FEE PAID:
RECEIPT #:
DocuuENT #: PR837630
PROPERTY ADDRESS: 100 NE 92 St Miami, FL 33138
LOT: 13 &14 BLOCK: 24
PROPERTY ID #: 11- 3206 - 013 -3290
SUBDIVISION: Miami Shores
[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 [ ] 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 [ 1
D [ 225 ] SQUARE FEET SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: (X] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [s] TRENCH [ 1 BED [ 1
N
F LOCATION OF BENCHMARK: F.F.E.: 11.85' NGVD.
I ELEVATION OF PROPOSED SYSTEM SITE [ 11.80 ] [I INCHES I FT ] [ ABOVE /I 33E7,0W IJ BENCHMARK /REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 47.80][J INCHESI FT ][ABOVE /ltBENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ 36.00] INCHES
THIS PERMIT IS FOR THE NORTH SIDE SYSTEM ONLY. 1— Install 900 gal. category-3 septic tank equipped with an
O approved filter. 2 -The licensed contractor installing the system is responsible for installing the minimum category of tank in
T accordance with sec. 64E-6.013(3)(f). 3- Install 225 sf of drainfield in trench configuration. 4- Perimeter of excavation area
shall be at least 2 ft wider and longer than the proposed absorption bed. 5- Invert elevation of drainfield to be no less than
8.36' NGVD. 6. Bottom of drainfield elevation to be no less than 7.86' NGVD. o ,c stei Tito remain.
THIS PERMIT IS NBC 3%F R ADDMON(s).
R
SPECIFICAT+ S BY:
APPROVED
PEDRO N OSPINA
DATE ISSUED: 03/09/2011
TITLE:
Dade CHD
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E - 6.003, FAC
v1.1.4
AP996883
EXPIRATION DATE : 06/07/2011
8E838419
Page 1 of 3
STATE OF FLORIDA'
DEPARTMENT OF HEALTH
'LIGATION FOR ONSITE SEWAGE DIS OSAkSYSTEM CONSTRUCTION-PERM
ass
I
neS E 00 2 3'x`,8
Site Plan submitted b
Plan-Approved_
County Health De
ALL CHANGES MUST BE APPRO VED BY THE COUNTY HHEALTI1 DEPARTMENT
c7it4015. 10/96 (Rein HRS-H Form 4015siktt map be use*
Mack NumbEr 014-002 401544