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PL-14-2468 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-223166 Permit Number: PL-11-14-2468 Scheduled Inspection Date: November 18,2014 Permit Type: Plumbing - Residential Inspector: Diaz, Osvaldo Inspection Type: Final Owner: WILLIAM J.JURBERG,R.ANDREW DE Work Classification: Septic once Job Address:9350 NE 12 Avenue Miami Shores, FL 33138- Phone Number (305)609-3851 Parcel Number 1132050070150 Project: <NONE> Contractor: CHAPMAN SEPTIC SERVICE, INC. Phone: (305)815-9901 Building Department Comments INSTALL 1350 GAL TANK AND 725 INSTALL 900 GAL Infractio Passed Comments TANK AND 250 INSPECTOR COMMENTS False Inspector Comments Passed HRS IN FILE Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid. November 17,2014 For Inspections please call:(305)7624949 Page 26 of 45 40u&kf Miami Shores Village Building Department artment f 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel:(305)795-2204 Fax:(305)756-8972 Ii INSPECTION LINE PHONE NUMBER:(305)762-4949 --- _= FBC 20 [0 BUILDING Master Permit No7L— ( '1— a�,j PERMIT APPLICATION Sub Permit No. RC 13 I(05 �0 ❑BUILDING ❑ ELECTRIC ROOFING REVISION ❑ EXTENSION ❑RENEWAL [PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP n2 �q CONTRACTOR DRAWINGS JOB ADDRESS: `1 JJr V I� �� /011'41)6 p City: Miami Shores County: Miami Dade Zip: 3 3 1-6 O Folio/Parcel#: 1l- 3�as'0(97,(Q���t� Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone: BFE: FFE: IU-.11�wm S Jvib4.r•c�Trs OWNER: Name(Fee Simple Titleholder):�k% i' xot fes) DE �Q'S -Z l &s Phone#: Address: 9 � n�L /o? 4a4— City: M1 QAu.J J State: Jam/ Zip: 5 -31 -39 Tenant/Lessee Name: Phone#: Email: n' G Q CONTRACTOR:Company Name: lJ_ 14T� 6'2rAy(_ Phone#: 5♦9s Address:,, `I bi all City:/xtad'4) State:Ti Zip:3.3o?(4.3 Qualifier Name: (2� I� ,, 0_A4Ajm,&6___ Phone#:'&p S•glS' !q C2 6)( State Certification or Registration#: 6P 9-qq`figo7 Certificate of Competency#: 6ftO 91 LgS7q DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ Square/Linear Footage of Work: Q070* *,M Type of Work: ❑ Addition ❑ Alteration Eld New ❑ Repair/Replace ❑ Demolition Description of Work:-:r�lasn 2 adARO, t q Specify color of color thru tile: r . • :��2. ._ . ; .>., Submittal Fee$ `w Permit Fee$ &Wl '<y CCF$ CO/CC$ Scanning Fee$ Radon Fee$ DBPR$ Notary Technology Fee$ Training/Education Fee$ Double Fee$ Structural Reviews$ Bond$ c TOTAL FEE NOW DUE$ ��J . OCD (Revised02/24/2014) 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 ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES, BOILERS, HEATERS,TANKS,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. Signature Signature OWNER r AGENT V CONTRACTOR The foregoing instrument was acknowledged before me this The foregoing instrument was acknowledged before me this day of �-%J 20 ( by 40 day of Ild 20 / by wh personally know to 44d�c4uwho is personally known to me or who has produced �- as me or who has produced as identification and who an oath. identification and who did take an oath. NOTARY PUBL C: NOTARY PUBLIC: Sig Sign:�� teary 3p� ••. 's tMER �q Print: '`•� �:- Notary Public-State of Flo]Assn. -- Print: C CCr�}Aw- �V _ �.� "'• c Onlm. ap res N Seal: Commission#F EE 17384Seal: =o: #FF 087868 'Q: Z� • O Boned Through National Notary .,9�•: N,,�p• Q ••. f f�F • C. CT'T ############################################################################################################ APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Nov 10 14.11:48a Chapman Septic Service 1-305-453-5537 p.1 t , Mission; Rick Scott To protecl,promote 8 improvethe health Governor Of all people in Florida through integrated �" I state.county&oommunityefforts. i John H.Armstrong,MD, FACS State Surgeon General 9 Secretary Vision:7o be the Healthiest State in'he Nation MASTER SEPTIC TANK CONTRACTOR CHARLES J. CHAPMAN PO BOX 431911 MIAMI, FL 33243 CHAPMAN SEPTIC SERVICE, INC. - Business Authorization: SA0910574 SM0941167 Florida Department of Health Divisior.of Oisease control and Health Protection a wwwr.FloridasNealth.aom . Bureau of Envinonmental Heallh TWITTER HealthyFLA 4052 Bald Cypress way,Bin A-08•Tallahassee,FL 32399-1710 FACEBOOK:FLDepartmentdHealth PHONE:8501245 4444 Ezt 2793 FAX 851X487-0884 3 YO1TU8E:koh Q .�•1� �i �1i`S�i xl� +�fri 41� FLORIDA DEPARTMENT OF HEALTH A 4; . �t CERTIFICATE OF AUTHORIZATION L„t LD f FOR SEPTIC TANK -CONTRACTING =��jj, i r. The Florida Department of Health hereby certifies the business or entity namebelow has bi 1 ,�. as satisfied the { requirements of Part III, Chapter 489, Florida Statutes,for septic tank contracting and has been duly authorized by the Department to provide septic tank contracting services under the name of �l i[f '- ' Ste•'! I i,I 4 CHAPMAN SEPTIC SERVICE INC. , CD L , U) (n I,.3?�•. I s Ih SA0910574 Aril 17 2013 t t _April March 31, 2015 } f Authorization Number Date Issued ' j sr Expiration Date I , rrx •�r it ;���, I,lrn.al;• ). Rick Scott, Governor a - IrtiS'v.• i ] MIAMa MIAMI-DADE COUNTY - STATE OF FLORIDA N/A October 30,2014 LOCAL BUSINESS TAX RENEWAL 230862 2014 -2015 APPLICATION RECEIPT:230862 DBA/BUSINESS NAME: STATE#SM0941167 CHAPMAN SEPTIC SERVICE INC BUS.COMMENCEMENT DATE:08/24/1988 SEC TYPE OF BUSINESS BUSINESS LOCATION: PLUMS SPECIALTY PLUMBING CONTRACTOR 10601 SW 184 TERR MIAMI, FL 33157 10 OWNER/CORP. APPLICATION DETAILS CHAPM- EPTIC SERVICE INC 1 f.E'.E PHONE -661-0628 � ^eceiptAMOUNT'�ee 30.00 I UM;A Fee 30.00 PO BOX 431911 Beacon;"ouncil Fee 15.00 M,lAP✓I:,FL 33243 Binoo Permit Fee 0.00 Nightclub Permit Fee 0.00 Multl-Municipal Contractor Fee 0.00 Restricted Contractor Fee 0.00 Library Fee 0.00 NAICS CODE: 238220 Transfer Fee 0.00 Doing Business 1r n h out a License Penalty 0.00 _.ata Penalty 0.00 - Ocr~i:n Cost 0.00 S Fe,,- 0.00 Frier Yeats Due 0.00 tom: -Irlt;recent',;Paid --_ - 75.00 1 TOTAL AMOUNT DUE: 0.00 if no longer in business,please notify us in writing. To pay online go to www miarn;dacle aov/taxcoil rtor Review and correct the information shown on this application. Tc �: mail; make check payable to: f1 rr�F-C.. ie County Tax Collector A 25%penalty will be assessed to anyone found operating Business Tax without a paid local business tax, in addition to any other 20^ NYV':id Av-,nue penalty provided by law or ordinance(Sec 8A-176(2)). Miam= FL 33128 To pay in person go to: A Certificate of Use and/or City Business Tax 200 NW 2nd Avenue ^receipt"' aISO be required. (30.5)270-4949.fax(?OF)372_-!3F,8 A service ,'ee of not less than$25.00 up to a minimum of 5% Will ue crc.rged for all returned checks. 't RETAIN FOR YOUF,f:E:;O:a.S 4 .................................................... ..................................................... ,.. MIAMI-DADE COUNTY- j DETACH HERE AND RETURN THIS PORTION VVI'Tia YOUR PAYMENT 4- STATE STATE OF FLORIDA N/A October 30,2014 LOCAL BUSINESS TAX RENEWAL 2014 -2015 APPLICATION J f 1 i l !'�I RECEIPT:230862 ?.0862_ IIIIIIiIIIIIIII�I�fll��l�� I��I'� IIil�I� I III STATE#SM0941167 BUSINESS LOCATION: 10601 &V 184 TERR MIAMI,F__ 33157 BUS. DATE:03;24/1983 SEC i"iFi;OF BUSINESS OWNER/CORP. PLUMS ;r ::�'!:�LTY PLUMBING CONTRACTOR CHAPMAN SEPTIC SERVICE INC 10 APPLICATION'-"- BUSINESS TAX Rc.':;cIPT OF PERMIT FOR THE BUSINESS PROFESSION S I O_ JPA - -AwE=EEN INFORMED OF ALL ZONING RESTRICTIONS IMPOSED ON THIS RECEIPT. SWEAR THAT -._ i-�. S -.AND CORRECT. ChAFtviAN SEPTIC SERVICE INC CES 'CHAPMAN PRES FO B:;;;431911 S;C'Jr: Ui <- G SEE INSTRUCTIONS ABOVE M'aW FL 33243 Pie-aso pay en?r l ...:rotiit.The amounts alae after Sept 30th include penalties per FS 205.053. if Received By Oct 31,2014 Nov 30.2014 Dec 31,2014 Jan 31,2015 Please Paje ';;:.v0 ;1,0.00 $0.00 $0.00 7000000000000000000000000230862li --00000750000LiJ000D0008 To: 13057568972 Page: 2/2 Date: 11/10/2014 11:30:35 AM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFI RMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CAA,EA' Terri Kerrigan Horizon Insurance. Inc. PHONE 941-755-9500 FAX (air Lig F Arc No:941-753-9472 7347 52nd Place E izonins.net Bradenton, FL 34203 INSURERS AFFORDING COVERAGE NAIC S INSURED INSURERA: American Safety Indemnity Company INSURERB: Chapman Septic Service, Inc. INSURERC: PO Box 431911 INSURERD: Mami,FL 33243-1911 INSURER E: INSURERF: COVERAGES CERTIFICATE NUMBER: 00000000-963477 REVISION NUMBER: 64 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLIS TYPE OF INSURANCE IPJSD POLICY NUMBERPOLICY EFF POLICY EXP WUVBnl VV LIMITS A COMMERCIAL GENERAL LIABILITY EPK-105007 08/04/2014 08/04/2015 EACH OCCURRENCE $ 1 000 000 CLAIMS-MADEEZ OCCUR P occurrence) r e $ 50,000 MED EXP(Any one person) $ 5.000 PERSONAL&ADV INJURY 1 $ 1 OOO 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,W0 POLICY[DPE° E]LOC PRODUCTS-COMP/Op AGG $ 2 OOO OOO OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED HIRED AUTOS AUTOS MA(Per 2rcident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB OCCUR MADE AGGREGATE DED RETENTION WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY YIN START ANY PROPRIETOR/EXCLUDERTNER/EXECUTIVE E.L.EACH ACCIDENT $ (MandatoUTD7 ER' OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) If yes describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY OMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedde,maybe attached it more space is required) Septic Tank Contractor License#SM0941167 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Village of N6ami Shores THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 10050 NE 2nd Ave Marro, FL 33037 AUTHO ZED REPRESENTATIVE TAK ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Printed by TAK on November 10,2014 at 11:28AM Nov 0514,02:22p Chapman Septic Service 1-305-453-5537 p.4 75 6 ',scl 7.? ac�® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDWYYYY) -ilw� 1 10/31/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE. DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: tf the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain poilctes may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER SUNZ Insurance Solutions LLC ID(Essential) NCONTACT AME; Jennifer Hau er c/o Essential HR, Inc. dba First Stair R PHONE 21a ase-1x86 251 O'Connor Ridge Blvd Suite 370 &MAIL Irving,TX 75038 ADDRESS: •ennifer_hau er firststarhr.com INSURERS)AFFORDING COVERAGE NAIC p INSURER A: SUNZ Insurance Company 34762 INSURED INSURER B: Aspen Re-London-Best Rating"A" Essential HR Inc., Essential HR 11 Inc, dba First Star HR INSURERC: Catlin S ndicat_e-Lloyds-Best Rating"A" 251 O'Connor Ridge Blvd INSURERD: Brit Syndicate-Lloyds-Best Rating"A' Suite 370 Irving TX 75038 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 22179121 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N07WTHSTANDING ANY REQUIREMENT,TERM 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE ADDL HRi POLICY EFF POLICY EXP POLICY NUMBER MMlDD MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE EJOCCUR A � PR MI S Ea aamrrence $ MED EXP(An one person) $ PERSONAL&ADV INJURY S GEN'LAGGREGATELIUMAPPLIESPER. GENERAL AGGREGATE $ I POLICY a PRO- �—I --,_-- JECT LJ LOC OTHER_ PRODUCTS-COMP/OP AGG $ Is AUTOMOBILE LIABILITY COMBINED SINGLE LIMITIs Fa accld rIt ANY AUTO BODILY INJURY(Perperaon) $ ALL OWJED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED HIREDAUTOS PROPERTY DAMAGE $ AUTOS S � UMBRELLA LY1B �] �OCCEACH OCCURRENCE $ EXCESS UAB AGGREGATE DED F RETENTIONS A COMPENSATION is !AND EMPLOYERS' LABILITY 00018402 10/1/2014 10/1/2D15 8T7 TE ETH PRWPRIETORMARTNERI YIN WCPE00000154 01 10/1/2013 10/1/21)14OFnEMEMBER EXCJDED? F—]NrA E.L EACH ACCIDENT $ 1,000,000 (Mandatory In NH) Y daecribelnder E.LDISEASE-EAEMPLO $ 1,000,000', DESCRIPTION O I PE RATIONS bebw E. DISEASE-POLICY LIMIT $ 1,UOD,0001 B Workers Compensation C This is for informational purposes ;Excess Coverage and nothing shall create any right O under such reinsurance_ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached h more space is required) Coverage provided for all leased employees but not subcontractors oP.CHAPMAN SEPTIC SERVICE INC. Effective date:10/1/2013 CERTIFICATE HOLDER CANCELLATION 61500002 Villa a of Miami Shores SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1000 NE 2nd Avenue THE EXPIRATION DATE THEREOF, NOTICE WELL BE DELIVERED IN Miami FL 33037 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Glen J Distefano s+. ©1988-2014AGORD CORPORATION. All rights reserved. ACORD 25(3014/01) The ACORD name and logo are registered marks of ACORD C2R7 NO.: 22179121 Todd Trowbridge 10/31/2C14 9:50344 NM (CDT) Page 1 of 1 l_�C • STATE of FLORIDA PST #: 13SC-1498877 DEPARTNZNT OF HEALTH APPLICATION #: AP 1123089 ONSITE SZK&GE TREATMdNT AND DISPOSCOpy DATE PAID: SYSTEM PAID: CONSTRUCTION PERMIT Florida Health Mlaml-Dade COun"MCEIPT #: . D.S, e'73t Pro ram DOCUMENT #: PR821740 CONSTRUCTION PERMIT FOR: OSTDS New APPLICANT: (R ANDREW DE PASS JTRS WILLIAM J JURBERG JTRS) PROPERTY ADDRESS: 9350 NE 12 Ave Miami,FL 33138 LOT: BLOCK: SUBDIVISION: PROPERTY ID #: 11-3025-007-0150 (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 THISYO PERTY. SYSTEM DESIGN AND SPECIFICATIONS T [ 900 ] GALLONS / GPD Septic CAPACITY A [ ] GALLONS / GPD N/A CAPACITY N [ ] GALLONS E INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] DOSING TANK CAPACITY [ ]GALLONS 0f ]DOSES PER 24 HRS #Primps [ 7 D I 250 3 SQUARE FEET SYSTEM R [ ] SQUARE FEET N/A SYSTEM A TYPE SYSTEM; [xI STANDARD [ ] FILLED { ] HOUND [ I I CONFIGURATION: [x] TRENCH [ ] BED [ ] N F LOCATION OF BENCHMARK: C/L of NE 12 Ave&East P/L Elev+8.90 I ELEVATION OF PROPOSED SYSTEM SITE [ 4.80 )[ INCHES FT ]I ABOVE SELON BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 34.80 1 (r1_NC_H19_Sj FT ] [ABOVE BELON BENCHMARK/REFERENCE POINT L D FILL REQUIRED: 10.001 INCHES EXCAVATION REQUIRED: [ 72.001 INCHES 0 1.-Install a 900 gal min.septic tank with an approved filter. 2.-The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance T with s.64E-6.013(3)(f), FAC. H 3.-Install 250 sf of drainfield in trench configuration. 4.-Install 42"of slightly limited soil at the bottom of the drainfield. E 5.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. R 6.-Invert elevation of drainfield to be no less than 6.50'NGVD. (Comments Continued on Page 2.) SPECIFICATIONS BY: Ken W Groce TITLE: APPROVED BY: TITLE: Engineering Specialist II Dade CHO 00 • DATE ISSUED: 11/08/2013 EXPIRATION DATa: 05/08/2015 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page l of 3 v 1.1.4 AP1123089 62912402 STAT$ OF FLORIDA PERMIT #: 13-SC-149972 DNPARTNIIIINT OF HZALTH APPLICATION #: AP 1123086 ONSITZ SNii M TRIMTHMM AND DISPO�0PY DSYSTEMATE PAID:PAID: CONSTRUCTION Florida Health Mlaml-Da CEIPT #: CONSTRIICTION PERbIIT O-S -D . &W II de Dount� rog m DOCUMENT #: PRS21703 CONSTRUCTION PERMIT FOR: OSTDS New APPLICANT: (R ANDREW DE PASS JTRS WILLIAM J JURBERG JTRS) PROPERTY ADDRESS: 9350 NE 12 Ave Miami, FL 33138 LOT: BLOCK: SUBDIVISION: PROPERTY ID #: 11-3025-007-0150 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 391.0065, 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 I /3S(� ] 8 / GPD Septic CAPACITY A I /a s .] -W= / GPD CAPACITY N [ I GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS 01 ]DOSES PER 24 HRS #Pumps [ ] D [ I SQUARE FEET SYSTEM R [ I SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD I ] -FILLED [ ] MDUHD I ] I CONFIGURATION: [x] TRENCH I ] BED I I N F LOCATION OF BENCHMARK: C/L of NE 12 Ave&:East P/L Elev+8.90 I ELEVATION OF PROPOSED SYSTEM SITE [ 1.00 ] I INCHES/ FT I[ABOVE/BELOW]BENCHMhPjt/REP'RRENCE POINT E BOTTOM OF DRAINFIELD TO BE [ 31.00 ] I INCHES/ FT I [ABOVE�BENCHMARK/RErzRENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: 172.00 ] INCHES o *"This pe s am nded by N.Gumbs on 4/14/2014 to relocate the house septic system."'* 1.-Install 1350 in.septic tank with an approved filter. T 2.-The li ntractor installing the system is responsible for installing the minimum category of tank in accordance H with s.64E-6.013(3)(0, FAC. 3.-Install 725 sf of drainfield in trench configuration. E 4.-Install 42"of slightly limited soil at the bottom of the drainfield. R 5.-Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption bed. (Comments Continued on Page 2.) SPECIFICATIONS BY: Ken W Grooe TITLE: APPROVED BY: TITLE: Engineering Specialist II Dade CHD Nicole I gaza- DATE ISSUED: 11/08/2013 EXPIRATION DATE: 05/08/2015 DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 1 of 3 v 1 1.4 "1123086 SE925669 APPLICATION #: STATE OF FLORIDA PERMIT #:13-SC-1499972 DEPARTMENT OF HEALTH DOCUMENT #:F1974715 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM �ti I CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:04/09/2014 FEE PAID:1 1 0.00 RECEIPT #:13-PID-2371839 APPLICANT: R ANDREW DE PASS JTRS WILLIAM J JURBERG JTRS AGENT: Cherokee Consulting, Inc PROPERTY ADDRESS: 9350 NE 12 Ave Miami, FL 33138 LOT: BLOCK: SUBDIVISION: ID#: 11-3025-007-0150 CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION SETBACKS [ ] [01] TANK SIZE [1] 1500.00 [2] [ ] [27] SURFACE WATER FT [ ] [02] TANK MATERIAL Concrete [ ] [28] DITCHES FT [ ] [03] OUTLET DEVICE [ ] [29] PRIVATE WELLS FT [ ] [04] MULTI-CHAMBERED [ Y / N ] [ ] [30] PUBLIC WELLS FT [ ] [05] OUTLET FILTER [ ] [31] IRRIGATION WELLS FT [ ] [06] LEGEND 1. 01-011-20SC3 2. [ ] [32] POTABLE WATER 70 FT [ ] [07] WATERTIGHT [ ] [33] BUILDING FOUNDATIONS 12 FT [ ] [08] LEVEL [ ] [34] PROPERTY LINES 25 FT [ ] [09] DEPTH TO LID [ ] [35] OTHER FT DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM [ ] [10] AREA [1] 735 [2] SQFT [ ] [36] DRAINFIELD COVER [ ] [11] DISTRIBUTION BOX HEADER X [ ] [37] SHOULDERS [ ] [12] NUMBER OF DRAINLINES 1. 7.00 2. [ ] [38] SLOPES [ ] [13] DRAINLINE SEPARATION [ ] [39] STABILIZATION [ ] [14] DRAINLINE SLOPE [ ] [15] DEPTH OF COVER ADDITIONAL INFORMATION [ ] [16] ELEVATION [ ABOVE / BELOW ]BM 28.20 [ ] [40] UNOBSTRUCTED AREA [ ] [17] SYSTEM LOCATION [ ] [41] STORMWATER RUNOFF [ ] [18] DOSING PUMPS [ ] [42] ALARMS [ ] [19] AGGREGATE SIZE [ ] [43] MAINTENANCE AGREEMENT L ] [20] AGGREGATE EXCESSIVE FINES [ ] [44] BUILDING AREA [ ] [21] AGGREGATE DEPTH [ ] [45] LOCATION CONFORMS WITH SITE PLAN FILL / EXCAVATION MATERIAL COPY , [ ] [46] FINAL SITE GRADING [ ] [22] FILL AMOUNT Florida Health Miami-Dade CounLY ] [47] CONTRACTOR Chapman(Chapman) [ ] [23] FILL TEXTURE O.S.T.D.S. &Wellrogram L[ ] [48] OTHER ADS ARC 24 [ ] [24] EXCAVATION DEPTH ( ABANDONMENT [ ] [25] AREA REPLACED 1j 1-311 ] [49] TANK PUMPED [ ] [26] REPLACEMENT MATERIAL [ ] [50] TANK CRUSHED & FILLED Comments: Comments are on page 2. CONSTRUCTION [ APPROVED / Dade CHD DATE: 11/03/2014 DISAPPROVED Engineering Specialist II Betsy Lange-Olmino(Department of Health in Mia FINAL SYSTEM [ APPROVED / DISAPPROVED ] , Dade CHD DATE: 11/03/2014 Engineering Specialist 11 BetsyLange- •mmo epartmen o ea th in Mia (Explanation of Violations on following page) DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 2 of 3 APPLICATION 123089 a STATE OF FLORIDA PERMIT #:13-SC-1499977 DEPARTMENT OF HEALTH DOCUMENT #:F1974208 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:10/11/2013 WE FEE PAID:375.00 RECEIPT #:13-PID-2295565 APPLICANT: R ANDREW DE PASS JTRS WILLIAM J JURBERG JTRS AGENT: Ken W Groce(Cherokee Consulting, Inc) PROPERTY ADDRESS: 9350 NE 12 Ave Miami, FL 33138 LOT: BLOCK: SUBDIVISION: ID#: 11-3025-007-0150 CHECKED [X1 ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION SETBACKS ( 1 [011 TANK SIZE [11 900.00 [21 [ 1 (271 SURFACE WATER FT ( 1 [021 TANK MATERIAL Concrete [ 1 (281 DITCHES FT ( 1 [031 OUTLET DEVICE [ 1 (291 PRIVATE WELLS FT ( 1 [041 MULTI-CHAMBERED ( Y N J [ 1 (301 PUBLIC WELLS FT ( 1 (051 OUTLET FILTER Polylok PL-68 [ 1 (311 IRRIGATION WELLS FT ( 1 [061 LEGEND 1. 01-011-04DC3 2. [ 1 [321 POTABLE WATER 40 FT ( 1 [071 WATERTIGHT [ J [331 BUILDING FOUNDATIONS 6 FT ( J [081 LEVEL [ 1 [341 PROPERTY LINES 5 FT ( 1 [091 DEPTH TO LID [ 1 (351 OTHER FT DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM ( 1 (101 AREA (ll 270 [21 SQFT [ 1 [361 DRAINFIELD COVER [ 1 [111 DISTRIBUTION BOX HEADER X [ 1 [371 SHOULDERS ( 1 [121 NUMBER OF DRAINLINES 1. 3.00 2. [ 1 [381 SLOPES ( 1 [131 DRAINLINE SEPARATION [ 1 [391 STABILIZATION ( 1 [141 DRAINLINE SLOPE ( 1 [151 DEPTH OF COVER ADDITIONAL INFORMATION [ 1 [161 ELEVATION [ ABOVE / BELOW IBM 32,64 ( 1 [401 UNOBSTRUCTED AREA ( 1 (171 SYSTEM LOCATION ( I [411 STORMWATER RUNOFF ( J [181 DOSING PUMPS ( 1 [421 ALARMS ( 1 [191 AGGREGATE SIZE ( 1 [431 MAINTENANCE AGREEMENT ( 1 [201 AGGREGATE EXCESSIVE FINES ( I [441 BUILDING AREA ( 1 [211 AGGREGATE DEPTH ( 1 [451 LOCATION CONFORMS WITH SITE PLAN FILL / EXCAVATION MATERIAL ( 1 [461 FINAL SITE GRADING ( 1 [221 FILL AMOUNT �o�� ( 1 [471 CONTRACTOR Charles J Chapman(Chapma ( 1 [231 FILL TEXTURE ( 1 [481 OTHER ADS ARC 24 ( 1 (241 EXCAVATION DEPTH Florida Health Miami-Dade County ABANDONMENT ( J [251 AREA REPLACED O•S.T .S. &WelllPrograrl 1 [491 TANK PUMPED [ J [261 REPLACEMENT MATERIAL I J 1' [ 1 [501 TANK CRUSHED & FILLED Comments: Comments are on page 2. CONSTRUCTION I APPROVED / Dade CHD DATE: 10/28/2014 DISAPPROVED 1' Engineer Specialist II Joseph R Piverger(Department of Health in Dade Cou FINAL SYSTEM [ APPROVED / DISAPPROVED J : Dade CHD DATE: 10/28/2014 Engineer Specialist 11 Josephiverger 7o—partment of Healthin Dade Co (Explanation of Violations on following page) DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.003, FAC Page 2 of 3 EH Dart+base v 1.0A AP1125089 EID1499977