PL-12-2042Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
nspection Number: INSP- 180861
Permit Number: PL -10 -12 -2042
Inspection Date: November 14, 2012
Inspector: Hernandez, Rafael
Owner: ACOSTA, JUAN CARLOS
Job Address: 128 NE 99 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1132060132270
Phone: (954)963 -0082
Building Department Comments
REPLACE DRAINFIELD INSTALL NEW 667 SQFT
DRAINFIELD
Infractio Passed Comments
INSPECTOR COMMENTS False
Passed
Inspector Comments
HRS APPROVAL IN FILE
7
,) •
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled
re- inspection fee is paid.
until
.
For Inspections please call: (305)762 -4949
November 26, 2012
Page 1 of 1
APPLICANT:
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
CONTRACTOR / AGENT:
LOT:
BLOCK: SUBDIV:
ID #:
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR
OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS.
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
EXISTING TANK INFORMATION
] GALLONS SEPTIC TANK /GPD ATU LEGEND:
] GALLONS SEPTIC TANK /GPD ATU LEGEND:
] GALLONS GREASE INTERCEPTOR LEGEND:
] GALLONS DOSING TANK LEGEND:
MATERIAL:
MATERIAL:
MATERIAL:
MATERIAL:
BAFFLED•[Y / N]
BAFFLED-[Y / N]
# PUMPS:[ ]
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON / / BY , HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS / PILLING / LEGEND ], ARE FREE OIL OBSERVABLE
DEFECTS OR LEAKS, AND HAVE A [ SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE ] INSTALLED
SIGNATURE OF LICENSED CONTRACTOR BUSINESS NAME
DATE
EXISTING DRAINFIELD INFORMATION
[ ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
[ ] SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X
TYPE OF SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ]
CONFIGURATION: [ ] TRENCH [ ] BED [ ]
DESIGN: [ ] HEADER [ ] D -BOX [ ] GRAVITY SYSTEM [ ] DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE INCHES [ ABOVE / BELOW]
SYSTEM FAILURE AND REPAIR INFORMATION
[
]
SITE
CONDITIONS:
NATURE OF
FAILURE:
FAILURE
SYMPTOM:
SYSTEM INSTALLATION DATE TYPE OF WASTE [ ],DOMESTIC [ ] COMMERCIAL
GPD ESTIMATED SEWAGE FLOW BASED ON [ ] METERED WATER [ ] TABLE 1, 64E -6, FAC
[ ] DRAINAGE STRUCTURES
[ ] SLOPING PROPERTY
] POOL [ ] PATIO / DECK [ ] PARKING
l
[ '] HYDRAULIC OVERLOAD [ ] SOILS
[ ] DRAINAGE / RUN OFF [ ] ROOTS
[ ] SEWAGE ON GROUND
[ ] PLUMBING BACKUP
REMARKS /ADDITIONAL CRITERIA
[ ] TANK
[
[ ] MAINTENANCE [ ] SYSTEM DAMAGE
[ `] WATER TABLE [ ]
[ -] D BOX /HEADER [ ] DRAINFIELD
SUBMITTED BY:
TITLE /LICENSE DATE:
nu Amu Aft /AO vi nna erli ti nna ,,hi nh maw nn* 1.,® »a ®ri1
Miami Shores Village
Building Department
30050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
FBC 20 l�
Permit No.
Master Permit No. PC. I 2-0(-12-
Z
b136I' ti 7�.,�
B DING
PERMIT APPLICATION
Permit Type: PLUMBING
JOB ADDRESS: 128 G c-fre-e-r
City: Miami Shores County: Miami Dade Zip: 33) 38
Folio/Parcei#: t) — C ° 0 t 3° 22 1
Is the Building Historically Designated: Yes NO ✓
OWNER: Name (Fee Simple Titleholder): L �'+ vl coos, os Aco -,
Address: ( ;Irv-)
Flood Zone;
60 R 2 3
City: State: Zip:
Tenant/Lessee Name: Phone#:
Email:
CONTRACTOR: Company Name: StA -Vecz 1 d e S I C co n Phone#: 50,§4)61 - 6 6 33
State: zip: f 71,2
Address:
City: t'A i'C i'v *-
Qualifier Name: I ems' ,,sc ce , t '�a`n
i
State Certification or Registration #: _ 1 .6'L Certificate of Competency #:
Contact Phone#: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Phone#:
Value of Work for this Permit: $
Type of Work °Address
Description of Work
Square/Linear Footage of Work CG "7
UNew °Repair/Replace
Repfr' ir- el( .
I1 ' ?Lti1+
DYP -Reid
°Demolition
a * * * * ** *012* ***** nee *** sum+ * * * * **e+** **** * **F ** ** eye***** ***e** *** ******** * *** * * ***** *****
Submittal Fee $ Permit Fee $ /157' CCF $ CO /CC $
Scanning Fee $ Radon Fee $ DBPR $ Bond $
Notary $ Training/Education Fee $ Technology Fee $
Double Fee $ Structural Review $
TOTAL FEE NOW DUE $ 115 •(J
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 perform:! to meet the standards of all laws regulating
construction in this jurisdiction. I understand that a separate permit must be secured for R1$ CTRICAL WORK, PLUMBING, SIGNS,
W ..I.I C, 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 $2500, the applicant must
promise in good faith that a copy of the notice of comonencernent and construction lien law brochure will be delivered to the person
whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement nwst be posted at the job site
for the first inspection which occurs seven (7) days after the building permit is issued In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged
Signature
or Agent
The foregoing instrument was acknowledged before me this
day of CC°F- , 201 2-, by NT) rr lac Acc +
who is personally known to me or who has produced Dr +isc r -
Lt % As identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
c
Tce 1,011,10,—)
My Commission Expires:
•'1'x•141''• TERESA J SOLOMON
` •': MY COMMISSION # EE131935
(407) 398-0153
COM
OVER BY t %/,,!i■■wireArt
APPROVED
Signature
Contractor
The foregoing instrument was acknowledged before me this LL
day of 101 , 20 l by -b�
who is personally known to me or who has produced 1°(--A
as identification and who did take an oath.
Plans Examiner
Structural Review
(Revised3 /1212At2XRevised 07 /1O107)(Revised 06/10 /2009)(Revised 3/15/09)
NOTARY PUBLIC
Sign: \\.‘"111111111 ''''''''
Print:
My Commission Expires:
en Y 9 /00,,,n
!O � '
/
+1 44441 **ate*
Zoning
Clerk
STATE OF FLORIDA
DEPARTMENT 08 HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION FERMXT
CONSTRUCTION PEWIT TOR: OSTDS Existna Medication
APPLICANT: Juan Carlos ACOSIS
PRCS+z. Y ACZRESS: 126 NE ee St Mimi, Fl. 33136
W 1012
rmrIT a :13 -SC- 1378352
APPI.ICOTXCN t : AP 1052536
BATE PAID:
L PAD:
RECEIPT 4:,
noctnerr a; PR859659
.61=41' 17
norms ID 11- 3203 -013 -2270
SURDITISION!
[SCTZON, TOWNSHIP, SANE, P gcm..`+7ii:'JBER1
[ TAX ID :DER]
SYSTEM NWT ss COi":S3RC'CrED IBS =COW,3't = WITS SPECIFICATIONS A: STA.'RL A'RD$ OF SZCIZO'1T
38I.4OSS, &.5., AND CRAFTER S4E -5, F.A.C. DEPTH •s APPA OF SYSTEM DBEs zMr GUARANTEE
SATISFACTORY P$'TiPMV0ANCE I'm ANY SPECIFTo PERIOD GIP Tr4E. ANT C A \'sU TN t a. VELIAL FACTS,
macs SERVED AS A BASIS VAR ISSUANCE OF Taus PE_ T, RE0UIRE THE AM :CANT 40 D:FY :OE
PERMIT APPLZCATicN. SUCH ) !?!_C !U $ MY RESULT 3\T Tars MEM= BEING *ai4$ NULZ �r^ VO: .
=SCARCE O' THIS PERMIT EOEa NQT NM= THE a' ICA i tF C COMPLIANCE A'Iza[ OTEER FEDERAL.
STATE. =LOCAL FEI§MITTINS REQUIRED POR DEVELOPMENT OT T LS MUM.
SYSl ( DESIGN AND SPECIFICATIC.TS
SW 3 LLONS f/ Sean sans ri CAPAC:22
GALLONS / N A CAPACITY
$ GALLONS GREASE =TRAMP= CAPACITY DaKEKMK CAPACITY SIN= TA :1250 CALLCNS;
] ammegs 1DStWC TANK CAPACITY [ ]GALLONS et :DOSES PER 24 >(RS *Pumps
a t 667 ] SWAPS mg?
R [ 3 SQUARE FEET
Arm sY53m3: txj summon
8 JR 2ScN: ] 3 = a9
SYSTEM
NIA Vs=
t i P' - -s`m
[x1 BED [
F LCCA 'ION OF S Ottt.0Ai X: FFE : 12.53' NGVD
t 3
tl
Z =NATI= of PR0pasED SYSTEM SITE 1 23110 I
2 BOTTOM CT =AIRFIELD TO BE t 8334 1
L
DFIT.RE¢DIYt :
INCHES
=Cuss
I t BC Vd DELcw DZ CHVARTi i E war
t_ I [ -- _ 4 SESTI S°C/s'� saIrE PCIE '
LaCi =�
ExCAVZare= MIMEO: t 72,00 ] =as
- insteCI es7 sq R Cre rifted.
- tr-.atall 42- cf wry li,r` ed so' under b can of drat-ri le:4
- Et vatic of bottom ca crantjgtd to be no - ess'an 8.11' N"GVD.
• Exist-mg 903 g septic tank to rcme n.
Tl^:.32r. cAu gor 5ea'g7.:s! +?:].-► *„ IVIC"r1' a
+fi i ri?2 3C,3 ::r1 iz tr ! ti eLO ? ",
time of n7-31 3m , n;; 77f;:..-.: ; a Fr; w roi,71.. trE� J ".
' , l!ue:ts7 S /1.3 irr3s< art crirve .«
-es I t �c
a'J � re �rt ! " [, r. eiJ SJ2711.2E:, .'^.
re.irt.STr vtiln •ra 47!' ti ZEE. C :r1 ` -2V.t [ i;
't `tot ,,CtS :- ,i17. The 7•�7[ _� _ _
SPECIFICATIONS ?Y:
Teresa Solo
TITLE: Laster suptze Tank Cantr::sows
: Engineer Spssa2affit IS
Dada dap
DR 4016, 40/09 ((bao );Zen all previous editions which may
znearporrated! 64E- "b03, FAC
i l ds- 1CS2534
not be usesi)
ENPrRATION DA E:
C=:22i2DD13
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