PL-12-728Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP- 172708 Permit Number: PL -4 -12 -728
Scheduled Inspection Date: October 10, 2012
Inspector: Hernandez, Rafael
Owner: FLORES, VANESSA
Job Address: 85 NW 101 Street
Miami Shores, FL
Project: <NONE>
Contractor: STATEWIDE SEPTIC CONNECTIONS
Permit Type: Plumbing - Residential
Inspection Type: Final
Work Classification: Addition /Alteration
Phone Number
Parcel Number 1131010180180
Phone: (954)963 -0082
Building Department Comments
REPLACE SEPTIC TANK AND 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 09, 2012
For Inspections please call: (305)762 -4949
Page 7 of 46
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DIPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICANT:
AGENT:
PRQPERTY ADDRESS:
LOTs 0 BLOCK: �, SUBDIVISION:
CHECKED [X] ITEMS' ARE NOT IN COMPLIANCE WITH STATUTE OR R.
TANK INSTALLATION SETBACI
[ ']` [01] TANK SIZE [1] ®G [2]. [ ] [27]
[ `"1 [02] TANK MATERIAL [ ] [28]
[- [03] OUTLET DEVICE [ ] [29]
[ 1 (04] MULTI- CHAMBERED [ Y / N [ ] [30]
[ ] [05] OUTLET FILTER 7 [ ] [31]
[ 4 [06] LEGEND % [32]
[ [07] WATERTIGHT M '[ 1 [33]
[ [08] LEVEL '1'C- . , L ] [34]
[� J
[09] DEPTH TO LID Ci if I ] [35]
DRAINFIELD INSTALLATIQN FILLEp`
[ ] [10] AREA [11 ISx /cJ2]/ r QFT" [ ] [36] r
[ ] [11] DISTRIBUTION BOX HEADER // [ [37]
[ 1 [12] NUMBER OF DRAINLINES ] [38]
[ ] [13] DRAINLINE SEPARATION 4 [ [39]
[ ] [14] DRAINLINE SLOPE
[ 1 [15] DEPTH OF COVER f ADDITIO
[ ] [16] ELEVATION [ABO ELO BM [ - [40] dt
[ ] [17] SYSTEM LOCATION -._ [ [41]
[ ] [18] DOSING PUMPS [ ] [42]
[ ] [19] AGGREGATE SIZE [ ] [43]
[ ] [20] AGGREGATE EXCESSIVE FINES [t.] -' [44]
I ] [21] AGGREGATE DEPTH [ .1 1451
[ [46]
FILL / EXCAVATION MATERIAL [ ' [47]
[ ] [22] FILL AMOUNT [ ] [481
[
1 [23] FILL TEXTURE
[ ] [24] EXCAVATION DEPTH
[ ] [25] AREA REPLACED
[ ] [26] REPLACEMENT MATERIAL
EXPLANATION OF VIOLATIONS / REMARKS:
[ ]
[ ]
[ ]
[ ]
PERMIT NO.
DATE PAID:
FEE PAID:
,RECEIPT #:
CONSTRUCTIO
S
A
L.
C1
0'
ABANDON1
[49] TJ
[50]
ISAPPROVED]
FINAL SYST PRO D /DISAPPROVED]•
IVliir "1IIth Street Miami, Florida 33168
Tel 786 - 402 -8656
)CHD
S.w f CHD
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E- 6.003, FAC
DATE :
DATE:
Page 2 of 3
Miami Shores Village REC
APR 24-2;
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 20
Permit No. PU
Master Permit No.
Permit Type: PLUMBING 9 O. ,�/ Q�j^
OWNER: Name (Fee Simple Titleholder): �/�3 i' 3 Fl Ei R€ Phone*. 306-
/59100 % 0
Address: /s( , /0 /S
City: /17 / A/7) / HO a 6,g State: F I r� Zip: 33 / 50
Tenant/Lessee Name: Phone#:
Email:
JOB ADDRESS: 8 1f ID ' 10 /
City:
Miami Shores County:
Folio/Parcel #: 11 r o (° 0 1
Is the Building Historically Designated: Yes
Miami Dade
Zip: 33/50
NO Flood Zone:
CONTRACTOR: Company Name: CS-1.Z' +''C LAS ei o C Phone #: /�2N. 17
Address: tr,Q 3 7 S 23 Srlree fi
City: 4 i \c a ry Oi' State: FL Zip: & OZ "3
Qualifier Name: T .C'c dO Io v Phone #:
State Certification or Registration #: _S.M o- n I -1 , 2 & 'a Certificate of Competency #:
Contact Phone #: Email Address:
DESIGNER: Architect/Engineer: Phone#:
Value of Work for this Permit: $ 24-DO Square/Linear Footage of Work: 1 5° S
Type of Work: ❑Address ❑Alteration ❑New PfRepair/Replace ❑Demolition
Description of Work: � �/1 (0 (,c, n )C--
rairl
Submittal Fee $ Permit Fee $ ..BYES 0
Scanning Fee $ Radon Fee $
Notary $ Training/Education Fee $
Double Fee $ Structural Review $
CCF $ 9'1
DBPR $
Fee $
CO /CC $
Bond $ -,;
�'t
TOTAL FEE NOW DUE $
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 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.
' Si
ignature gn atu
Owner or Agent ,� t,
The f egoing instrument was acknowledged before me this
day f egoing
20�y�°�`!`4 �� °�� ,
eiceewho is personally known to me or who has produc
11
i.o.c:As identification and who did take an oath.
cgk.S \,\A. NOTARY PUBLIC:
Contractor l
The foregoing instrument was acknowledged before me this
day of 414 , 20 l2, byNi(
who is personally known to me or who has produced'° for
as identification and who dipfiNI}Apth.
_ \\ ‘‘ d Q l aO,a;'r,,,
Sign:
Print:
My Commission Expires:
**
rit" ,,,, ,, ASHAI(I S. BRONSON- MARCELLUS
.���` — °e% p r State 01 Florida
M Comm. oExpl`rts eg I't '
oQ Commission # EE 186231
.`' n Bonded Th .nigh National Notar Assn.
2j- /2--
(Revised 07 /10 /07)(Revised 06 /10/2009)(Revised 3/15/09)
Plans Examiner
Structural Review
Sign:
Print:
My Commission Expires:
,7 /,9/G�if�� ya'
Zoning
Clerk
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT:
Vanesa Flores
AND NEP
PERMIT It :13 -SC- 1404778
APPLICATION #:AP1069114
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR873414
PROPERTY ADDRESS: 85 NW 101 St Miami, FL 33150
LOT: 10
BLOCK: 2 SUBDIVISION: Navarro Sub
PROPERTY ID #: 11- 3101 - 018 -0180
(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 (
900 ] GALLONS / GPD
0 ] GALLONS / GPD
0 ] GALLONS GREASE INTERCEPTOR CAPACITY
] GALLONS DOSING TANK CAPACITY
New Septic Tank
D ( 150 1 SQUARE FEET
R [ 0 ] SQUARE FEET
TYPE SYSTEM: [x] STANDARD
CONFIGURATION: [x] TRENCH [ ] BED [ ]
A
I
N
F
I
E
L
D
0
T
H
E
R
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
CAPACITY
CAPACITY
(MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
]GALLONS @( ]DOSES PER 24 HRS #Pumps
Trench configuration drain SYSTEM
SYSTEM
[ ] FILLED [ ] MOUND
LOCATION OF BENCHMARK: F.F,E., 13.10' NGVD
ELEVATION OF PROPOSED SYSTEM SITE
BOTTOM OF DRAINFIELD TO BE
FILL REQUIRED:
[ 26.40 ] [I INCHES / FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE
[ 56.40 ] [I INCHES Y FT ] [ ABOVE 4 BELOW b BENCHMARK /REFERENCE
[ 0.00) INCHES EXCAVATION REQUIRED: [ 30.00] INCHES
POINT
POINT
Inspector to verify the existing septic tank is properly abandon before final approval.
'Invert elevation of drainfield to be no less than 8.90 ft. NGVD.
'Bottom of drainfield elevation to be no Tess than 8.40 ft. NGVD.
-The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance
with sec. 64E- 6.013(3)(f). F.A.C.
'THIS PERMIT IS NOT FOR " ADDITION(s) ".
DH 4016, 08/09
Incorporated:
Carlos M
�(ii►i_i�
ITLE: Dade
iiRPPF
Carlos M I
04/19/20
TITLE:
(Obsoletes all previous editions which may not be used)
64E -6.003 FA
The colit; aciur (or designee) is required to perform a
soil boring adiatehtko "the drainte(d excavablafb %M
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 tee will be assessed it the contractor is not
at th,: jobsite at the arranged time
EXPIRATION DATE: 07/18/2012
5E868613
CHD
Page 1 of 3
t r-LC)11.1LJA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number/
PART II • SITE PLAN-
CI •
Scale: Each block represents 5 feet and 1 inch = 50 feet.
IT_ 7 (•:-.1-1-77•7••
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Notes: Flor e5 &5 Nv■1 101 . NiN 0 rt-,5 3 31s0
Site Plan submitte b :
Plan Approv
By
clioeir)-6,01 0? •
__CL,9--IrY•e-- I/) 6 c 0
1
Signature C-0 11-"cf-k,"
Title /
Not Approved Date C, L/ fi ',//
County Health Departmer
CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
0144015. 10196 (Replaces HRS-H Form 4015 which may be used)
(Stock Number: 5744-002-4015-6)
Page 2 of