PL-04-295Miami Shores Village
A Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
BUILDING RECEOvED Permit No. 1 v-- 2q.5
PERMITAPPLICATION 3 2504 aster Permit No. 2PO4 - 4
FBC 2001
Permit Type (circle): Building
Owner's Name (Fee Simple Titleholder)
Owner's Address0 �4C)� �9. t, I
City I 6u I State
Tenant(Lessee Name
Job Address (where the work is being done)
Electrical Plumbing Mechanical Roofing
Zip _06 .
Phone #
City Miami Shores Village County Miami Dade Zip C -D-), l
Is Building Historically Designated YES NO,
Contractor's Company Name t Phone #1� ,?Z��
Contractor's Address C9 t
City d I 1 State Zip s
Qualifier
State Certificate or Registration No. QQ 0 �JLoh _ Certificate of Competency No.
G6(- oS'b 147
Architect/Engineer's Name (if applicable) .
$ Value of Work For this Permit (2 , � cs • 6b
New
Type -of Work:. []Addition ❑Alteration
Describe Work. I t c
Phone #
Square Footage Of Work:
Demolition
Submittal Fee $ Permit Fee S V CCF $1a CO/CC
Notary $ Training/Education Fee $ , �� Technology Fee $
Scanning $ Z�v Radon $ Zoning
Code Enforcement $ Structural Plan Review. $
TotalFee Now Due $
(Continued on opposite side)
Bond $ =_ZVOO - C)O 0o
Bonding Company's Name (if applicable)
Bonding Company's Address
City
State
Mortgage Lender's Name (if applicable)
Mortgage Lender's Address
City
state
Zip
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 comm-aacement must be posted at the job sine
for the first inspection which occurs seven (7) days after the building permit is issued, --fn thenbsence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Si Signatipf
Owner or Agent Contractor
The foregoing instrument was acknowledged before me this
day of , 20 _, by
who is personally known to me or who has produced
As identification and who did take an oath.
The foregoing instrument was acknowledged before me thisi 3 4-R
day of 0 2001 by c.51( mc) 15C ,-e�
who is personally known to me or who has produced
I -e-� 7 5 as identification and who did take an oath.
NOTARY PUBLIC: NOTARY PUBLIC•
Sign: Sign. W �L�'t
Print: P ' 1✓i�e �;ENCIO
81997
My Commission Expires: My Commission E e I= SJanuSION 8 D2
1�' January 19,2M8
ea�eaYlvu►Qanaubbumtwfte
APPLICATION APPROVED B % '�� e--, Plans Examiner
Engineer
Zoning
Chc 05/13/03
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ X ]New System [ ]Existing System [ ]Holding Tank
[ ]Repair [ ]Abandonment [ ]Temporary
FEE PAID $
RECEIPT
OSTDSNBR :04-1561,
[ ] Innovative Other
[ NA ]
APPLICANT: Vickers, Roberti B. AGENT: SA0990924, Suarez Guillermo
PROPERTY STREET ADDRESS: 1401 NE 101 St Miami Shores FL 33138
LOT: 3 BLOCK: 3 SUBDIVISION: Miami Shores Bay Par
[Section/Township/Range/Parcel No.]
PROPERTY ID #: 11-3205-023-0140 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E-6,FAC
3EPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT,
MUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS
?ERMIT BEING MADE NULL AND VOID. ISSUANCE OF TRIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM
=OMPLIANCE WITH OTHER FEDERAL, STATE OR LOCAL, PERMITTING REQUIRED FOR PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
[ 1200 ]'Gallons SEPTIC TANK MULTI-CHAMBERED/IN SERIES: [Y ]
[ 0 ]Gallons MULTI-CHAMBERED/IN SERIES: [Y ]
d [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
[ 375 ]GALLONS DOSING TANK CAPACITY [ 84 ]GALLONS @ [6 ]DOSES PER 24 HRS # PUMPS[ 1 J
[ 360 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ 360 ]SQUARE FEET SYSTEM
TYPE SYSTEM: [ N ]STANDARD [ Y ]FILLED L N ]MOUND [ N ]
CONFIGURATION: [ N ]TRENCH [ Y ]BED [ N ]
LOCATION TO BENCHMARK:_8.59'X-M FF E/R _
ELEVATION OF PROPOSED SYSTEM SITE [ 38.3 J [ INCHES ] [ BELOW] BENCHMARK/REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ 43.1 l [ INCHES ] [ BELOW]BENCHMARK/REFERENCE POINT
FILL REQU'IRED:[ 9.6 ]INCHES EXCAVATION REQUIRED: [ 58.8 ] INCHES
ETHER REMARKS:
i
PECIFICATIONS BY
PPROVED BY:
ATE ISSUED: 9/9/04
TITLE:
TITLE: Elagilneer I Dade CHD
1 4016, 03/97 (Obsoletes previous editions which may not be used)
itock Number: 5744-001-4016-0) lostds conp_4016-11
EXPIRATION DATE: 3/9/06
Page 1 of 2
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305-795-2204
Printed: 10/19/2004
Applicant: ROBERT
Owner: VICKERS
JOB ADDRESS: 1401 NE 101
Plumbing Permit
Permit Number: PL2004-295
VICKERS
ROBERT
ST
Page 1 of 1
Contractor A LEAGUE CONTRACTORS, INC. Contractor's Address: 11400 N. KENDALL DR. SUITE 205
Local Phone: 305-234-5222
Parcel # 1132050230140 Legal Description: M SHORES BAY PK ESTS PB 55-83 LOT 3 BLK 3 LOT SIZE 99.500 X
Fees:
Description
Amount
FEE2004-10263
Building Fee
$175.00
Total Fees: $483.97
FEE2004-10264
CCF
$1.20
Total Receipts: $483.97
FEE2004-10265
Training and Education Fee
$0.40
FEE2004-10266
Scanning Fee
$3.00
FEE2004-10267
Builders Bond
$300.00
NOV
FEE2004-10268
Technology Fee
$4.37
17 PAID
Total Fees:
$483.97
Permit Status: APPROVED Permit Expiration:
Work: New septik tank and drainfield
Signed:
4/12/2005 Construction Value: $2,000.00
(INSPECTOR)
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility, for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
Miami Shores Village
10050 NE 2nd Avenue
Phone: 305-795-2204
Printed: 10/19/2004
Applicant: ROBERT
Owner: VICKERS
JOB ADDRESS: 1401 NE 101
Plumbing Permit
Permit Number: PL2004-295
VICKERS
ROBERT
ST
Page 1 of 1
Contractor A LEAGUE CONTRACTORS, INC. Contractor's Address: 11400 N. KENDALL DR. SUITE 205
Local Phone: 305-234-5222
Parcel # 1132050230140 Legal Description: M SHORES BAY PK ESTS PB 55-83 LOT 3 BLK 3 LOT SIZE 99.500 X
Fees:
Description
Amount
FEE2004-10263
Building Fee
$175.00
Total Fees: $483.97
FEE2004-10264
CCF
$1.20
Total Receipts: $483.97
FEE2004-10265
Training and Education Fee
$0.40
FEE2004-10266
Scanning Fee
$3.00
FEE2004-10267
Builders Bond
$300.00
FEE2004-10268
Technology Fee
$4.37
Total Fees:
$483.97V
j 78A In
Permit Status: APPROVED Permit Expiration:
Work: New septik tank and drainfield
Signed:
4/12/2005 Construction Value: $2,000.00
(INSPECTOR)
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations pertaining thereto and in strict
conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In accepting this permit I assume responisibility for all work
done by either myself, my agent, servants or employes.
Signed: (Contractor or Builder) BY:
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
[ X ]New System [ ]Existing System
[ ] Repair [ ] Abandonment
CENTRAX #: 13 -SG -20611
DATE PAID:
FEE PAID $
RECEIPT
OSTDSNBR 04-1561--N
[ ]Holding Tank [ ] Innovative Other
[ ]Temporary [ NA ]
APPLICANT: Vickers, Robert B. AGENT: SA0990924, Suarez Guillermo
PROPERTY STREET ADDRESS: 1401 NE 101 St Miami Shores FL 33138
LOT: 3 BLOCK: 3 SUBDIVISION: Miami Shores Bay Par
[Section/Township/Range/Parcel No.]
PROPERTY ID #: 11-3205-023-0140 [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E-6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. 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 PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1200 ]Gallons SEPTIC TANK MULTI-CHAMBERED/IN SERIES: [Y ]
A [ 0 ]Gallons MULTI-CHAMBERED/IN SERIES: [Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 375 ]GALLONS DOSING TANK CAPACITY [ 84 ]GALLONS @ [6 ]DOSES PER 24 HRS # PUMPS[ 1 ]
D
R
A
I
N
F
I
E
L
D
[ 360 ]SQUARE FEET PRIMARY DRAINFIELD SYSTEM
[ 360 ]SQUARE FEET SYSTEM
TYPE SYSTEM: [ N ]STANDARD [ Y ]FILLED [ N ]MOUND [ N ]
CONFIGURATION: [ N ]TRENCH [ Y ]BED [ N ]
LOCATION TO BENCHMARK: 8.59'NGVD FF E/R
ELEVATION OF PROPOSED SYSTEM SITE [ 38.3 ] [ INCHES ] [ BELOW]BENCHMARK/REFERENCE POINT
BOTTOM OF DRAINFIELD TO BE [ 43.1 ] [ INCHES ] [ BELOW]BENCHMARK/REFERENCE POINT
FILL REQUIRED:[ 9.6 ]INCHES EXCAVATION REQUIRED: [ 58.8 ] INCHES
OTHER REMARKS:
SPECIFICATIONS BY: RAM, Arrieta
APPROVED BY: Arrieta, Rolando
DATE ISSUED: 9/9/04
TITLE:
TITLE: Engineer I Dade CHD
EXPIRATION DATE: 3/9/06
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0) [ostds-cons-4016-1] Page 1 of 2
This permit is for a unique blackwater, alternative filled/lift-dosing, low pressured~
and dual -bed system to serve the entire single-family residence [existing plus addition].
The design is undere a Florida State's registered engineer.
Install 1200 gal. dual-chambered and minimum category 3 septic tank, equipped with an
approved filter and a solid vertical deflector on the outlet device.
Install 375 gal. single -chambered and minimum category 3 lift -dosing tank, equipped with
a visual -sonorous alarms to be ready for testing at the moment of the final inspection; one
pump, certified as suitable for distributing sewage effluent, to dose 84 gal. max. 6 doses
per day, entirely dosing both drainfields each time through a manifold simultaneously.
The licensed contractor installing the system is responsible for installing the minimum
category of tank in accordance with sec. 64E -6.013(3)(f), FAC.
The existing septic system shall be abandoned under a separate permit
Install 2 x 320 sf filled drainfields, [using bundles of MPS -11 as per design replacing
the unsuitable soil in the site with 42" of slightly limited sand at the bottom, extended
12" wide as a barrier all around the perimeter of the required area.
As a lift -dosing system the header pipes connections and transmissions lines shall be
sealed.
As a filled system 4' min. shoulders and designed slopes shall be provided as well as 6"
minimum cover and sod stabilization as finishing.
Invert elevation of drainfield to be no less than 5.35' NGVD.
Bottom of drainfield elevation to be no less than 5.00' NGVD.
SPECIFICATIONS BY: RAM, Arrieta, Roland
APPROVED BY: Arrieta, Rolando
DATE ISSUED: 9/9/04
TITLE:
TITLE: Engineer I Dade
EXPIRATION DATE: 3/9/06
CHD
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0) [ostds_cons_4016-1] Page 1 of 2
STATEOF FLORIDA
DrkFARTMENT OF HEALTH
.ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
A_t�
PPLICANT: R9 be /j / V(,
LOT: BLOCK: SUBDIVISION
PROPERTY ID #: (Section/Township/Range/Parcel No. or Tax ID Number]
//32 S D a d y' /j�"/0 157 -
TO
STTO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN:, M YES [ ] NO NET USABLE AREA AVAILABLE: C2•2 (o ACRES
TOTAL ESTIMATED SEWAGE FLOW: d �r%`ac GALLONS PER DAY RESIDENCES -TABLE 1 -HER-TABLE 2)
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE OR 500 GPD/ACRE
UNOBSTRUCTED AREA AVAILABLE: �� SQFT/ UNOnBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK/ REFERENCE POINT LOCATION: N f� i �• V/ 4�i�p�,}� /�
ELEVATION OF PROPOSED SYSTEM SITE IS l/.� [INCHES/FT] [ABOVE/BELOW]
AGENT:
u ^
PERMIT
IKj '4 • e. /o / ST r
BENCHMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: A) A FT DITCHES/SWALES: —A lid_ FT NORMALLY WET? ( ] YES [A NO
WELLS: PUBLIC: )41 h FT LIMITED USE: AdA FT PRIVAE: 4114 FT NON -POTABLE: A)1114 FT
BUILDING FOUNDATIONS: .4W-� FT PROPERTY LINES: WFT POTABLE WATER LINES: FT
SITE SUBJECT TO FREQUENT FLOODING;
i 10 YEAR FLOOD ELEVATIOX, FOR SITE:
QATT_ DDACTT.10 T4T1n'/1DMAMTn&1 CTMW 1
[ j YES [k] NO 10 YEAR FLOODING? [ ) YES [X NO
A)114 FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
.) /lw-T -
Munsell Color Textu a Depth
-Aqz. &Z L,, d to
to
tom
1 v to
to
to
to
USDA SOIL SERIES:
0V1L t1lVr 1LG 1171'%Az%1n f11V/\ 011G L ^ // ,3. ®J
MunsellC 3 r Texture Depth
®P 4 to
to
to
to / 0
a to
to
t to
to
�¢
to 92
USDA SOIL SERIES:
OBSERVED WATER TABLE: A INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE PERCH D / APPARENT]
ER
ESTIMATED WET SEASON WA TABLE ELEVATION: INCHES [ ABOVE BE IS NG GRADE.
HIGH WATER TAB VEGETATION: [ ] YES [) NO MOTTLING: [ j YES EPTH: `INCHES
SOIL TEXTURE/LOA ING RATE FOR SYSTEM SIZING: C '�On DEPTH OF EXCAVATION:�y INCHES
DRAINFIELD CONFIGURATION: [ �] RENC [ BE ( OTHER (SPECIFY) 0 4z
REMARKS/ADDITIOkAL CRITERIA: C�►'w'L -Z _ •�'^"'tJ
SITE EVALUATED BY:/
'e
DH 4015, 10/96 (Replaces HRS For a ._31 which may be used)
(Stock Number: 5744-003-4015- ,
DATE : �_ //. v K
Page 3 of 3
INSTRUCTIONS:
PERMIT NUMBER:
APPLICANT:
AGENT:
LOT, BLOCK, SUBDIVISION:
PROPERTY ID NUMBER:
Permit tracking numbtr by County Health Department.
Property owner's full name.
Property owner's legally authorized representative.
Lot, block, and subdivision for lot.
27 character number for property (property appraiser ID number or section/township/range/parcel number).
PROPERTY SIZE:
Check if property at site conforms to submitted site plan. Record net usable area available - lot area exclusive of
all paved areas and prepared road beds within public rights-of-way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW:
Record the estimated sewage flow for the establishment from Table I (residence) or Table 2 (non-residential),
Chapter I OD -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA:
Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter IOD -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION:
Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE I SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. { - ] SHOT [ - ] SHOT [ - ] SHOT
4
- - o 1 ` 56
- ®STATE OF FLORIDA #, P IT
F- DEPARTMENT ]TH;;
x..
O' ., ., ry :
ONSITE SEWAGE DISPOSAL SYSTEM
`q 0WIE SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT : a 6•z�` �:..� , %1 AGENT: r
P LOT w 0 BLOCK: SUBDIVISION:
PROPERTY/ hip/Ran a/Parcel No. or Tax ID Number)
laf7 % A i Y' . %f"f Y • I19� 'nr M, f�'/ e./ir i
TO BE COMPLETED BY" ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER UALIFIED PERSON ENGINEER'S MUST
PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMIT A COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: .YES
[ ] NO NET USABLE AREA AVAILABLE. AiCRES
TOTAL ESTIMATED SEWAGE FLOW: 30 0 GALLONS PER DAY SIDENCES-TABLE 1 OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE 500 'GPD/ACRE
UNOBSTRUCTED AREA AVAILABLE: - q /SQ�F'jT f UNOBSTRUCTED AREA
REQUIRED: ` �^ SQFT
BENCHMARK/REFERENCE POINT LOCATION: j(/�f4td�
ELEVATION OF PROPOSED SYSTEM SITE IS NCH];b/FT]<(A_BgA/BELO—BENCHkiRKAtEFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: �� FT DITCHES/S ALES: A4 FT NORMALLY WET? [ ] YES ] NO
WELLS: PUBLIC: /[I FT LIMITED USE: AM- FT PRIVATE: I(�f FT NON -POTABLE: 'FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: FT POTABLE WATER LINES: FT
SITE SUBJECT TO FREQUENT FLOODING: [ ES ()lf NO 10 YEAR FLOODING? [ ] YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: _ FT".MSL/NGVD
r
SOIL PROFILE INFORMATION SITE 1 ----------- ------ -- --- ----
MunsellColor Texture /Depth Munsell C for Texture Denth'
- _�to e r to
t0 �t0
aY ^ �t0 $ to
to 0v/1 � ( 617" --to
' to If to
to to
to to
to—
IL
to
USDA SOIL SERIES:.E USDA SOIL SERIES.+
dr�►'�
,2) cit%
OBSERVED WATER TABLE: 'INCHES [ABOVE / BELOW], ISTING GRADE. TYP • ERCHED APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION: . r INCHES ( ABOVE / BELOW EXISTING GRADE.
•HIGH WATER TABLE VEGETATION: [ ] YES [ NO MOTTLING: [ ] YES [] NO TH.
INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING: iO f� DEPTH OF EXCAVATION: NO-OUINCHES
DRAINFIELD CONFIGURATION: { ] TRENCH [] BEb OTHER (SPECIFY)
REMA S( ITIONAL CRITERIA:
r
SITE EVALUATED BY: - --".""" ?" ') , ,''f DATE; /
..� Page 3 of 3
DH 4015, 10196 (Replaces HRS -H Form" 4015 [Page 31 Ith maybe used) r
(Stock Number: 5744-003-4015-1) ,
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department. t l
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION: Lot, block, and subdivision for lot.
y
PROPERTY ID NUMBER: 27 character number for property (property appraiser ID number or section/township/range/parcel number).
PROPERTY SIZE: Check if property at site conforms to submitted site plan. Record net usable area available lot area exclusive of
all paved areas and prepared road beds within public rights-of-way or easements and exclusive of streams, lakes,
normally wet drainage ditches, marshes, or other such bodies of water.
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table I (residence) or Table 2 (non-residential),
Chapter I OD -6, FAC. Record the authorized sewage flow for the lot based on net usable area and water supply
(1500 gallons per day per acre for private water supplies and 2500 gpd per acre for public water supplies). If
authorized sewage flow does not equal or exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA: Record the square feet of unobstructed area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter IOD -6, FAC. The unobstructed area must be contiguous to the drainfield.
BENCHMARK INFORMATION: Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the
elevation of the proposed system site in relation (above or below) to the benchmark.
MINIMUM SETBACKS: Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION: Record information on tot's subject to flooding. For lots subject to flooding record t0 year flood elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil
identification will use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals
must be clearly documented. Provide USDA soil series if available, record "UNK" if the series cannot be
determined.
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, USDA soil maps,
and historical information. Indicate if there is high water table vegetation present. Indicate if mottling is present
and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK SITE I SITE 2 SITE 3
[ + ] SHOT H.I. H.I. H.I.
H.I. [ - ] SHOT [ - ] SHOT [ - ] SHOT
_-� STATE OF -FLORIDA
' DEPARTMENT OF HEALTH- ff'
= AP CATION FOR ONSITE SEWAGE DISPOSAI&S,YST M CONSTRUCTI PRMIT
WE low
Kermit Application Number
------ PART II - SITE PLAN --------------------
Sofale: Each block represents 5 feet and 1 inch = 50 feet. f d`
Notes:
Y
Site Plan submitted by: -67 C'3.�rfna
Signature Title
F Plan Approved Not Approved Date
By County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
G
ON 4015, WN (Replaces HASH Form 4015 which may be used) Page 2 of 3
(Stock Number: 5744.002-40151:)
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Inspection Date: 07/18/2007
Inspector: Levrock, James
Owner: VICKERS, ROBERT
Job Address: 1401 101 Street NE
Miami Shores Village, FL 33138 -
Project: <NONE>
Contractor: A LEAGUE CONTRACTORS, INC.
Buildina Deoartment Comments
Permit Type: Imported Permit
Inspection Type: Final
Work Classification: <NONE>
0)00000
Phone Number (305)790-5899
Parcel Number 1132050230140
Block: Lot:
Phone: 305-256-0306
New septik tank and drainfield MASTER BP2004-489
JUL 18
Ins if m nts
Passed
l
Failed
Correction
Needed
Re -Inspection
Fee
($75)
No Additional Inspections can be scheduled until
re -inspection fee is paid
Monday, July 16, 2007 Page 2 of 2