PL-12-1390Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 176346 Permit Number: PL -7 -12 -1390
Scheduled Inspection Date: August 01, 2012
Inspector: Hernandez, Rafael
Owner: DAVIS, ROBERT
Job Address: 384 NE 94 Street
Miami Shores, FL
Project: <NONE>
Contractor: A SUPER SEPTIC TANK, INC.
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Septic
Phone Number
Parcel Number 1132060136140
Phone: (05)364 -0113
Building Department Comments
DRAIN FIELD REPLACEMENT
Passed
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
July 31, 2012
For Inspections please call: (305)762 -4949
Page 19 of 30
STATE OF FLORIDA'
DEPARTMENT OF HEALTH:
QNSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
PERMIT NO i (Yrs 2.
DATE PAID:
FEE PAID:
RECEIPT ft-
APPLICANT:
AGENT:
PROPERTY ADDRESS:
LOT:
BLOCK:
SUBDIVISION:
0
= = = = = _ — — _ — _ — _ — _ — — — _ —
CHECKED IX] ITEMS ARE ; NOT IN - COMPLIANCE WITH. STATUTE
TANK INSTALLATION
[01] TANK SIZE [1] [2]
[02] TANK MATERIAL 4 e r P
OR RULE AND MUST BE CORRECTED_.
[03] OUTLET DEVICE
[04] MULTI- CHAMBERED [Y / N,]
[051 OUTLET FILTER
[06] LEGEND ! --
[07]". WATERTIGHT
[08] LEVEL
109] DEPTH TO LID
DEPTH OF
SETBACKS
[27] SURFACE WATER
[28] DITCHES
[29] PRIVATE WELLS
[30] PUBLIC WELLS
] [31] IRRIGATION WELLS
]" [32] POTABLE WATER LINES
] [331 :. . RUt :DING FOUNDATION
.[34] PROPERTY LINES
tas "...° OTHER '
DRAINFIELD INSTALLATION
[10] AREA11] 2'r [21 sari-
[ [11] DISTRIBUTION ,BOAC HEADER,
[ .. ] [12] NUMBER OF DRAINLINES
[ ] [13] DRAINLINE SEPARATION 4
[ 1, [14] DRAINLINE SLOPE O , 0
[ ] [15]
J [16]
[17]
[18)
[ 1 [19]_
t ] [201
1
DOWER
ELEVATION [ABOVE/BELOW] BM
SYSTEM. LOOATIOIV
DQStNG PUMPS
AGGREGATE SIZE
�E''FINEI
FILLED/ MOUND "SYSTEM
[36] j DRAINFIEID COVER
[37] SHOULDERS
[38] SLOPES;_ '
[39] ' STABILIZATION
FT
FT`
FT
Cr FT
1 4 FT
FT
FT
AGGREGATE EXCESSIV
[213:: AGGREGATE DEPTH
FILL /,EXCAVATIN MATER'AL
[22] FILL AMOUNT
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[2S] AREA REPLACED..:
Mg) REPLACEMENT MATERIAL
gN/'i+T DNPOP \VIOLATIONS / EIVIARC'S:-
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STQRMWATER RUNOFF
L421 . " ALARMS�`
[43] ''MAINTENANCE AGREEMENT
[44] BU'1'LD1N0'AREA
[45] LOCATION CONFORMS WITH SITE PLAN
I J [46] FINAL SITE GRA G
[ ] . [471 CONTRACTOR - . ` i W 4),
[48] -OTHER
ABANDONMENT'
[4,91 ;' .TANK PUMPED„,„:_;„
_._1
[50]' :TANK CRUSHED & FILLED
CONSTRUCTION' [APP A PROVED'
FINAL SYSTEM [AP � �IBAPPI OVED] t:
DH• 4016 (Page 2), 10/97 (Previous Editions: May Be Used
Stook -Number`. 5744 -002- 4016 -4
PT 1: Applicant
PT 2: Installer/Onntractor
$wilding Department
PT 4: Healtt epartrnOr , "
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 20P
Permit Type: PLUMBING.
OWNER: Name (Fee Simple Titleholder):
Address:... S 'k 'C---> lam- l '
City: t rp : 1f? State: '4°4 Zip: � 1
Permit No.
Master Permit No. I q L-1 2 ®1310
e#3. f }
Tenant/Lessee Name °, Phone#:
Email:
JOB ADDRESS:
Sr
City: Miami Shores County: Miami Dade
Folio/Parcel # :- *- .c�k_?
Zip:
Is the Building Historically Designated: Yes NO
Flood Zone: ---�
CONTRACTOR: Company Name: / Sfp � i Z phone#: #..„ 7 Ft aili
Address: 7 7di Leto ° L
City: i qlz? State: -2-7,9 Zip: `i 3 47 f A
Qualifier Name : Phone#: 3 05-3" 9- a( /'3
State Certification or Registration #: • 2-.7
Certificate of Comjs~teney. #: d 0'72- 2'
Contact Phone #: S-6 ` 9 is" Email Address: 5'57 3c' c- e . o --
DESIGNER: Architect/Engineer:
Phone#:
Value of Work for this Permit: $ Cp Square/Linear Footage of Work:
OA1tration °New epair/Replace
Type of Work: °Address
Description of Work:
°Demolition
Submittal Fee $ .00 �� Permit Fee $ 0 � , CCF $ CO/CC5 $
Scanning Feet (5`' "� Ra'�n Fee $ DBPR $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
Bond $
TOTAL FEE NOW DUE $0 R 5
fda j, D
UM g� ip iy'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 FT.IYCTRICAL 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 $2500, the applicant must
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the t mperson si te
for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
The fo
day of
who is
Owner or Agent
g instrument Nas ac owledgecj efore
,20 by �, c
o me or who has produced `F
identification and who did take an oath.
NOTA
Sign:
Print:
My Commission
IC:
u�
** *444(4** *4444
APPROVED BY
State of FM a
xp'jds,c,,, Notary Public - 23.2015
? • : My Comm. Expires Se 128810
• Commission Rotary Assn.
,'sue rough Nation
>$bof�+x3x ** eti' * ** * * * * * **
The foregoing instrument was acknowledged before me this
day of 1-13 , 20 by JI ID ~JJ
who is personally known to me or who has produced t'
as identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires:
II I II I II I//
\`\\\ ,
14,0
t
,•,, e.�a���SS,\�`�
14 ****** *+ kak****** *+ k+ k**** *******ds *******+)•ik*4Mag*********
Plans Examiner
Zoning
Structural Review Clerk
(Revised 07 /10/07)(Revised 06 /10/2009)(Revised 3/15/09)
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT 4RECEIPT #:
DOCUMENT #: PR880577
PERMIT #: 13-SC-1416006
APPLICATION #: API075229
DATE PAID:
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Robert Davis
PROPERTY ADDRESS: 384 NE 94 St Miami, FL 33138
LOT: 1 -4
BLOCK: 46 SUBDIVISION: Miami Shores
PROPERTY ID #: 11- 3206 - 013 -6140
[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 [
A [
N [
K [
750 ] GALLONS / GPD Existign Septic Tank to remain
] GALLONS'/ GPD
0 ] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY
CAPACITY;
CAPACITY,
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
]GALLONS @[ JDOSES PER 24 HRS #Pumps
D [ 225 ] SQUARE FEET Trench configuration drain SYSTEM
R [ ] SQUARE FEET SYSTEM
[ ] FILLED [ ] MOUND [ ]
A TYPE SYSTEM: °[x) STANDARD
I CONFIGURATION: [x] TRENCH
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
[ ]
[ J BED [ ]
F.F.E., 10.01' NGVD
[ 2.52 ] [I INCHES I/ FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE
[ 20.52 ] [) INCHES f FT ] [ ABOVE /) BELOW b BENCHMARK /REFERENCE
L
D FILL REQUIRED:
Split sytem (north) with 400 gpd of 800 gpd.designed by a P.E Jose Moraga lic# 11515
O *Invert elevation of drainfield to be no less than 8.80 ft. NGVD. -
T *Bottom of drainfield elevation to be no less than 8.30 ft. NGVD.
*Install 12" of slightly limited soil under the bottom of the drainfield.
- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed or drain trench.
E -The system is sized for 5 of bedrooms with a maximum occupancy of 10 of persons (2 per bedroom), for a total
estimated sewage flow of 400 gpd.
[ 0.00] INCHES EXCAVATION REQUIRED: [ moo] INCHES
POINT
POINT
H
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DH 4016, 08/09
Incorporated:
Carl
07/19/2012
Icaza
TITLE:
TITLE:
r
64E-6. oo »e a ract0r (ar desieditions n ruurea to pe' m t be
soil boring. a,d ceant to the drainfield excavaa i aie DOH
time ut final inspection. Prior to Final A'>�
inspector shall witness the soil boring and compare the
results to the original site evaluation submitted. A
reinspection tee will be assessed it the contractor is not
at the iobsite at the arranged time
used)
Dade
EXPIRATION DATE: 10/17/2012
588774912
CHD
Page 1 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART II - SITE PLAN-
Scale: Each block represents 5 feet and 1 inch = 50 feet.
•
1"-tD2 rr)
e--
•
• 1
Notes:
C
• -1\°C I
Signature
Not Approved
Site Plan submitted by:
Plan Approve
By
\AttCHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
AI
L-‘-)6--1-1---e-2-- ) o
f-sr
, '
Title
Date L:; 1 i
County Health Department
DH 4015. 10/96 (Replaces HRS-H Form 4015 which may be used)
C744 flV •IVIC
Page 2 of
— DO NOT
7701 W 18 LA
33014 HIALEAH
A,
SeeIg
mis IS ONLY' A
I D NOT PERMIT THE
,•: o TO YlOIAYE'ANY OR
ZONING OF t
colony- OR COM NOR
i DOES IT EXEMPT THE
Hamm FROM ANY «num
LC
NiXA cAtO t OF
H
PAYMAIT
TAx
COLLECTOR
10/31/2011
09010043001
0000:49:50
SEE OTHER SIDE
PER SEPTIC:TANK
DO NOT FORWARD
A SUPER SEPTIC TANK INC
ANDREW ZERO PRES
7701 W 18 LA
HIALEAH FL 33014
a super septic tank
3053640349 p.1
'It'" CERTIFICATE OF LIABILITY INSURANCE
DATE (MWD YYVY)
07//27/2012
PRODUCER
ECONOMY INSURANCE AGENCY
1800 WEST S8 ST SULTE 139
F11ALEAH, FL 13014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POL1 IES BELOW.
A SUPER SEPTIC TANK
7701. WEST 18 LANE
HIALEAHH. FL 33014
INSURERS AFFORD1M3 COVERAGE
IN5U IMA A:
ASCENDANT INSURANCE CO
NAIL 0
EnterNA[C#
INSURER &
EDEN NALCII
INSURER C:
EnterNAICH
JN$ua Ir0:
Eater NA101
INSURERIE
EactNA1G#
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWI7HS•tANDiNG
ANY REQUIREMENT, TEAM 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. AOOREGA1 E OMITS SHOWN MAY HAVE BEEN AEOUCED EY PAID:CLAIMB.
INCA
LTR
ADO'L
MAO,
TYPE OF INSURANCE
FQI.ICY NUMBER
POLICY EFFECTIVE
DATE (NIMJDDNsr}
POLICY ExPMRATtCN
DATEtMWDDryV}
,re
A
GENERiN.LIAM90./TY
►'.'IOOMMERIOPL GENERAL UABIUTY
Ei'1380534
08127/2011
'
08/2712012
''EACH OCCURS=
3300000
:2
ORURO TO RENTED
PR IISESI1910001A(tln08)
1:300000
■ ■ CLAIMS MADE 1' Doom
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$3 00000
IBEN'L ADGREAATE L IMITAPPLJIEt3 PER
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PRODUCTS • WAIF/OP AGG
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3300000
❑ FOL1cY • PROJECT0 Loc
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AUTOMOBILE LIABILITY
❑ ANY AUTO
❑ ALL OWNED AUTOS
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$
BODILY INJURY
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TIVINITVITIETV IWII nCb
1411AI1d1 SHORES VILLAGE HALL
10050 NE 2 AVENUE
MIAIVti SHORtES, FLORIDA 33138
ACnCtf IN minimum'
rllwv rr1r11 ~III
SHOULD ANY OPUS ABOVE DESCRIBED POLICIES DE CANCELLED DER :Arne
THE
EXPIRATION DATE THEREOF, mE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
MALL DAYS WRITTEN NOTLCETOTHE CERTIFICATE: HOLDER NAMED TO THE LEFT.
BUT PALLURE 70 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANT KIND UPON
THE INSURER. ITS AtiENTBOAREPRESENTATIVES.
AUTHORIZED REPRESENTATIVE _
t0 /t0 39Vd
3ONt12ff1SNI M11O 033
CORPORATION 1888
ZEe1:e39S0E 1,2:09 ZIEZ /LIZ/L0