PL-12-718y
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 172671 Permit Number: PL -4 -12 -718
Scheduled Inspection Date: October 04, 2012
Inspector: Hernandez, Rafael
Owner: MARK THIBODEAU, TIMOTHY BARNUM
Job Address: 736 NE 94 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Drainfield
Phone Number (305)905 -5757
Parcel Number 1132060141680
Phone: (954)963 -0082
Building Department Comments
REPLACE 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
October 03, 2012
For Inspections please call: (305)762 -4949
Page 5 of 23
iq
�i3 - � 79-7d2 1�-
APPLICANT:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL, SXSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
AGENT: _e -c J� k
PROPERTY ADDRESS: .3 4, A,/ ' •
PERMIT NO.
DATE PAID:
FEE PAID:
RECEIPT #:
Pic
LOT: /I-12_ BLOCK: ej .5 SUBDIVISION: PROPERTY ID # s I /-•312 (i 4 -6i -JL?C)
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTEP•
TANK INSTALLATION
[ 1 (011 T A N K SIZE [1] C (21._._...
[ l [021 TANK MATERIAL
[ ] (03] OUTLET DEVICE
[ 1 [04] MULTI- CHAMBERED [1
[ 1 [051 OUTLET FILTER "irti.
1 ] [06] LEGEND
I 1 [07] WATERTIGHT
[ 1 [08] LEVEL
[ ] (09] DEPTH TO LID
1
1
3
1
y [1
DRAINFIELD INSTALLATION
(101 AREA [1]j c'XJ) '[2] QFT
[11] DISTRIBUTION BOX _ HEADER_
[121 NUMBER OF DRAINLINES �..yS
(13] D12P.INLINE SEPARATION ;; ` �-/ .,
[14] DRAINLINE SLOPE ✓
(15] DEPTH OF COVER J
[161 ELEVATION [ABOVE'BEt.,OW BM
[171 SYSTEM LOCATION
[18] DOSING PUMPS
[19] AGGREGATE SIZE dy1
[20] AGGREGATE EXCESSIVE FINES
[211 AGGREGATE DEPTH
FILL / EXCAVATION MATERIAL
(22] FILL AMOUNT / . ',
[231 FILL TEXTURE •
(24] EXCAVATION DEPTH
[251 AREA REPLACED
[26] REPLACEMENT MATERIAL.
EXPLANATION OF VIOLATIONS / REMARKS:
[ 1
[ ]
[ 1
[
CONSTRUCTION „jAPPROVEDYDISAPPROVED] s 11)41.e4 CHD
FINAL SYS [APPRO DISAPPROVED] : V ` 2� 1 c) c`”' cw
ajsr3,�.�� -e s�®L
SETBACKS
[27] SURFACE WATER
[28] DITCHES
[29] PRIVATE WELLS
(30] Pt7BLIC WELLS
[31] IRRIGATION WELLS
[321 POTABLE WATER LINES
[33] BUILDING FOUNDATION
(34] PROPERTY LINES
[351 OTHER
FT
FT
cg' S' FT
a26 FT
FT
FT
FILLED / MOUND SYSTEM
[ ] (36] DRAINFIELD COVER
( 1 [37] SHOULDERS
[ 1 [38] SLOPES
[ ] [391 STABILIZATION
ADDITIONAL INFORMATION
[ (401 UNOBSTRUCTED AREA
[ -1 [41] STORMWATER RUNOFF
[ ] [42] ALARMS
[ ] (43] MAINTENANCE AGREEMENT
[ (441 BUILDING 'AREA
( 1 [45] LOCATION CONFORMS WITH SITE PLAN
[ '� (46] FINAL SITE 0
[`"I (47] CONTRACTOR
[ ] (48] OTHER
ABANDONMENT
[ ] (49] TANK PUMPED / /
[ 1 (50] TANK CRUSHED & FILLED
DE 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, VAC
DATE: L/- 4Q- I L
DATE
Page 2 of 3
BUILDING
PE ' TAP
FBC 2��1
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
ICATION
Permit Type: PLUMBING
Permit No. 0 Z 1 I
Master Permit No.
OWNER: Name (Fee Simple Titleholder): KO►v- Th D G d i rro + h, Phone #:
Address: / M2 NS C04-
City: 1`q StfOre.S
State:
Zip: 35!
Tenant/Lessee Name: Phone #:
Email:
JOB ADDRESS: 1 NE. 94-- g"
City: Miami Shores County: Miami Dade Zip: g 3 ( 36t
Folio/Parcel #: 11 —" 2.CC, — Ot°-F-1680
Is the Building Historically Designated: Yes NO k Flood Zone:
CONTRACTOR: Company Name: & 4 )1d. , 1 C Cr oNi Phon e G I -6,6
Zip:
Address: bOX 3 -S
City: tio1 l � f 'wQoc! State:
Qualifier Name: ✓ 1 it&G J c)rn O ^ Phone#:
FL
State Certification or Registration #: M O�"} 1 2-6 2 Certificate of Competency #:
Contact Phone #:
DESIGNER: Architect/Engineer: Phone #:
Email Address:
Value of Work for this Permit: $ 11+O 2 Square/Linear Footage of Work:
Type of Work: 'OAddress ❑Alteration ONew Repair/Replace
Description of Work: ge. J (O'Cv « 1n ld
ODemolition
Submittal Fee $ Permit Fee $ 4°
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
CCF $ CO /CC $
DBPR $ Bond $
TOTAL FEE NOW DUE $ 1 12- • ��
Bonding Company's Name (if applicable)
Bonding Company's Address
City State
Zip
Mortgage Lender's Name (if applicable) 7'
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 AI'r''DAVIT: 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.
wn r Agent
The foregoing instrument was acknowledged before me this 1
day of a 20 142°, by 11 TA — 11d P)aireturn
who is personally known to me or who has produced FLA
D i i.Ac,et1&' As identification and who did take an oath.
NOTARY PUBLIC:
cz/...•••••••-----
Sign:
Print:
Signature
ctor
The foregoing instrument was acTa►owledged before me thi�
day of �� L , 20 t, byl " ✓ ,
who is personally known to me or who has produced 1
as identification and who did take an oath.
ollutliii,,,,
NOTARY PUBLI 1 *��0 4 +,1 07., yo ?"
049 li r�?
•" vp k TERESA J SOLOMON
MY COMMISSION # EE131935
PIRES November 08, 2015
My Commission Expires:
com
ign: 'AP.,_ e ,
.,„
int:+'. �am lOt �b���i
;':d
y Commission Expires: /i '•. ?X 3 . i
*//,:-/Ii ttaI �����0 \` \��
***** * * * ** ** * * *** * * ***** **** ***,************:,******************************** ** ** ** ** *** ** *** ** * *** ** ***m***
(
APPROVED BY 23'I Z— 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
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Mark Thibodeau
1
PERMIT #: 13-SC-1405144
APPLICATION #: AP1069335
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR873284
PROPERTY ADDRESS: 736 NE 94 St Miami, FL 33138
LOT: 1112
BLOCK: 65 SUBDIVISION:
PROPERTY ID #: 11- 3206 - 014 -1680
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
FOR 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 Existinq septic tank to remain CAPACITY
A [ 0 ] GALLONS / GPD CAPACITY
N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS 8[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 225 ] SQUARE FEET Trench configuration drain SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [x] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: F.F.E., 12.30' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED:
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
1 0.00 3 INCHES
26.40] [I INCHES i FT ] [ ABOVE BELOW I BENCHMARK /REFERENCE POINT
[ 62.40 ] [I INCHES ( FT ] [ ABOVE 4 BELOO BENCHMARK /REFERENCE POINT
EXCAVATION REQUIRED: [ 36.00] INCHES
*Invert elevation of drainfield to be no Tess than 7.60 ft. NGVD.
*Bottom of drainfield elevation to be no Tess than 7.10 ft. NGVD.
'THIS PERMIT IS NOT FOR " ADDITION(s) ".
Carlo
Alt
TITS Dade CFO
04/18 • • ,
TITLE:
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
he contactor (or designek) bs.le,quired to perform a AP1069335
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
EXPIRATION DATE: 07/17/2012
SE868489
Page 1 of 3
TEZPFC6Rli5r""""4"-rw
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Nurnenac r
• PART II SITE PLAN-
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Site Plan submitted
Plan Approve
By
• Az&
LL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
0H 4015, 10196 (Repines HRS-H Forml 4015 which may be used)
(Stock Number: 5744-002-4015-6)
Date
Tide
County Health Departmc
Page 2 o