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PL-17-1530 Permit NO P 17 Miami Shores village Pe /t ry'p&Pl�b�5� Resildo 10050 N.E.2nd Avenue NE '. w0to boa p r e l0 Miami Shores,FL 33138.0000 .` , h� a Phone: (305)795-2204 Issue©aI �017 Expiration: 12/17/2017 Project Address Parcel Number Applicant 899 NE 92 Street 1132060050020 JWBHB MANAGEMENT CORP Miami Shores, FL Block: Lot: Owner Information Address Phone Cell JWBHB MANAGEMENT CORP Contractor(s) Phone Cell Phone Valuation: $ 500.00 ALFONSO SEPTIC CONTRACTOR INC (786)251-4099 Total Sq Feet: 0 Type of Work:PUMP AND ABANDON SEPTIC TANK Available Inspections: Type of Piping: Inspection Type: Additional Info:PUMP AND ABANDON SEPTIC TANK HRS Approval Bond Return: Final Classification:Residential Scanning:3 Review Plumbing Fees Due Amount Pay Date Pay Type Amt Paid Amt Due Bond Type-Owners Bond $500.00 Invoice# PL-6-17-64260 CCF $0.60 06/08/2017 Credit Card $50.00 $770.10 DBPR Fee $2.25 DCA Fee $2.25 06/20/2017 Check#:005478 $770.10 $0.00 Education Surcharge $0.20 Bond#:3437 Notary Fee $5.00 Permit Fee $150.00 Scanning Fee $9.00 Technology Fee $0.80 Work without Permit Fee $150.00 Total: $820.10 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 responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work. OWNERS AFFIDAVIT: I ce t all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. thermo uthorize the above-named contractor to do the work stated. �- June 20,2017 Authorized Signature:dwineir / Applicant / Contractor / Agent Date Building Department Copy June 20,2017 1 DIVISION OF Environmental Health v0 Floihida Health 4A, �y Miami-Dade County �D eQ QSTDS/Well Division 11805 SW 76th Street•Miami,FL 33175 O Inspector l" C.._'� Date-0 �7 Z�• Z�� Address_ _ ,^ OSTDS# Comments: Signature. 31 Miami Shores Village RECEIVED � Building Department JUN 0 R 7P17 l 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 4"�Od � ' Tel:(305)795-2204 Fax:(305)756-8972 R INSPECTION LINE PHONE NUMBER:(305)762-4949 S FBC 201 L� BUILDING Master Permit No. 1 C9 5 PERMIT APPLICATION Sub Permit No. ❑BUILDING ❑ ELECTRIC F-� ROOFING ❑ REVISION Ej EXTENSION ❑RENEWAL F-IPLUMBING ❑ MECHANICAL PUBLIC WORKS CHANGE OF ❑CANCELLATION [:] SHOP CONTRACTOR DRAWINGS JOB ADDRESS: !?'2 2 /J C 7 o2 5 7- City: City: Miami Shores County: Miami Dade Zip: Folio/Parcel#: 11-32D,104225-11D026 Is the Building Historically Designated:Yes NO A Occupancy Type:_13- Load: Construction Type: Flood Zone: BFE: FFE: OWNER:Name(Fee Simple Titleholder):A (u " B _ Me�UT-- no/1 P Phone#: Address: Ste- f/ F - 9) g-7- City: H1 b P(( S 61c) n e 5 State: ��la Zip: 3 Tenant/Lessee Name: Phone#: Email: CONTRACTOR:Company Name: A1r-®lllSeS '�n�(ce C0QT/146- OA. A&(° Phone#:R(a-2S/=C/®19 Address:13g1 -t dae 15T ?16 S( l!/a(ica 6L �-/b City: /-�1 is��(�C Ll State:_ (2 14- Zip: �CJl7 Qualifier Name:A[ ' Phone#: 7F6,-,251-c(of State Certification or Registration#: Sk c9 7 L �b:� Certificate of Competency#: 5A. 0171!q DESIGNER:Architect/Engineer: Phone#: Address: City: State: Zip: Value of Work for this Permit:$ �f� �— Square/Linear Footage of Work: Type of Work: ❑ Addition ❑ Alteration ❑ New / ❑ Repair/Replace ❑ Demolition Description of Work: a G A '1 °,1« 4r .';x� t'fi:� bra '• •� Specify color of color thru tile: Submittal Fee$ V�- o • Permit Fee$ X0 CCF$ CO/CC$ Scanning Fee$ 4""::i CA3 Radon Fee$ �L Z DBPR$ Z Notary$ - C7 Technology Fee$ G ' i Training/Education Fee$ Double a ��0 Structural Reviews$ Bon ^^OI TOTAL FEE NOW DUE$ 2:-IO° (O (ReAsed02/24/2014) 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$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection will not be approved and areins ection fee will be charged. a , C Signature �' Signature O NER or AGENT /CONTRACTOR The foregoing instrument was acknowledged before me this Th oregoing instrument was acknowledged before me this � 1 day of 20 20 (7 ,by , ' k_day of —U N 20 ,by is ^!who who is personally known to) "T[ � k�► �.3�'who is pers((onlIally known tome or who has produced s gmeor has produced� S ` A 7O— s3 C) identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Sign: .. Print: MAHARAI K.GONIALEZ 602 EXPIRES:November 2,2020 Seal gg Notary Public-State Florida Seal: if g�� o.=My Comm.Expires May 27,2018 a$,os�.cP' Bonded Thtu Notary Public Underwriters ;;",7 Commission Commission#FF 097726 APPROVED BY ! Plans Examiner Zoning Structural Review Clerk (Revised02/24/2014) Re Miami hoes Village Building Department �►R ° 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel- (305)795.2204 Fax: (305)756.8972 Notice t® Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation *insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Fact Brochure: An employer in the construction industry who employs one or more part-time or fa11-time employees,including the owner,must obtain workers'compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if- 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. /�� Signature: net State of Florida County of Miami-Dade The foregoing was acknowledge before me this 3l day of ,20 . By who is personally known to me or has produced 12 as identification. MAC Notary as s .y SEAL: =° $ Notary pvbft-State of Florida My Comm.Expires May 27,2018 �. �- Commission FF 097726 Alfonso Septic Contractor Inc 1391 West 36 St Hialeah,FL 33012 Date: State of f1 Cir i dq County of Q,-A 1 Cx(4-4 I "b a Before me this&day of 2017 personally appeared a1 who,being duly sworn,deposes and says: That<he or she>will be the only person working on the project located at: q N - Otto t "32o o-6c>S- oozo actor sig ature //Sworn to and subscribed before me this$day of ` V 2017. Personally known Produced Identification K Identification Produced MAKARAI K.GONZAI MY COMMISSION#GG 044602 EXPIRES:November 2,2020 Bonded Thru Notary Public Undervvriters rint,Type or Stamp Name of Notary Detail by Entity Name Page 1 of 2 Florida Deoaifinent of State D1V1-.S10;a OF CORPORATIONS I Department of State / Division of Coroorations / Search Records / Detail By Document Number/ Detail by Entity Florida Profit Corporation JWBHB MANAGEMENT CORP. Filing Information Document Number P05000109887 FEI/EIN Number 81-0679701 Date Filed 08/08/2005 State FL Status ACTIVE Principal Address 2223 PEMBROKE RD HOLLYWOOD, FL 33020 Mailing Address 2223 PEMBROKE RD HOLLYWOOD, FL 33020 Registered Agent Name&Address BARAK, B 2223 PEMBROKE RD HOLLYWOOD, FL 33020 Name Changed:04/19/2007 Officer/Director Detail Name&Address Title PRES BARAK, B 2223 PEMBROKE RD HOLLYWOOD, FL 33020 Title SEC/ BARAK, H 2223 PEMBROKE RD HOLLYWOOD, FL 33020 Annual Reports Report Year Filed Date 2015 04/11/2015 http://search.sunbiz.org/Inquiry/corporationsearch/SearchResultDetail?inquirytype=EntityN... 6/8/2017 Detail by Entity Name Page 2 of 2 2016 04/18/2016 2017 04/26/2017 Document Images 04i2612017--.ANNUAL REPORT View image in PDF format 04,118/2016--ANNUAL REPORT View image in PDF format 04/1 1120 1 5 ANNUAL REPORT View image in PDF format 041l 312014 ANJN.U6L.aE.Pp..RT View image in TDF format 03/27/2013 ANNUAL REPORTI Me.,magem PDF format 04L2312012 ANNUAL REPORT View image ii FDF format 01127/2011 ANNUAL REPORT View image in PDF format 03/0912010 ANNUAL REPORT View image in PDF format g;.!,Q.,6/2_Qp9_,_8NNUALRE.PORT Vi.w image in PDF fonnat� 04/23/2008 ANNUAL REPORT View image in PC}F format 0411912007 ANNUAL REPORT View image in PDF format 04,1=2006 ANNUAL REPORT View image in PDF format 06/08/2005 Domestic Profit View image in PDF fornia http://search.sunbiz.org/Inquiry/corporationsearch/SearchResultDetail?inquirytype=EntityN... 6/8/2017 REGISTERED SEPTIC TANK CONTRACTOR JOSE BOLANOS 1391 WEST 36 STREET HIALEAH, FL 33012- ALFONSO SEPTIC CONTRACTOR INC Business Authorization: SA0171957 SR0971276 Registration Expires on September 30, 2017 Local Business Tax Pecei Pt Miami-Dade County, State of Florida -THIS IS NOTA BILL-DO NOT PAY LBT 7223484 BUSINESS NA M EILOCA TION RECEIPT NO. EXPIRES ALFONSO SEPTIC NEW BUSINESS SEPTEMBER 30, 2017 CONTRACTORINC 7505093 Must be displayed at place of business 1391 W 36 ST Pursuant to County Code HIALEAH,FL 33012 Chapter BA-Art.9&10 OWNER SEC.TYPE OF BUSINESS PAYMENT RECEIVED ALFONSO SEPTIC CONTRACTOR 196 SPECIALTY PLUMBING BY TAX COLLECTOR INC CONTRACTOR 45.00 04/1812017 rin r(8 ,IRNINfI Al Fft2r+t1 SA0171967 CREDITCARD-174)36827 ThisLoeei BWr=sTaxpacdpladycm ampaymtsttd#mL cat BusinessULIto FmdptisnotaltcarM perait,warunmWN��lmv�� wtac,�yto�b ywlmat►y uret�t arrmngwAnThe INWPTNQ above mist bediapleyedoonall commercial vehides-Miami-DadaOWeSec 83-9& Fbr weirdo-radon.visit•,•••R•^t80idadsao+tRwceolled� JOSE BOLANOS ALFONSO SEPTIC CONTRACTOR INC 1391 WEST 36 STREET HIAJ FAu FL 33012- _ FLORIDA DEPARTMENT OF HEALTH CERTIFICATE OF AUTHORIZATION FOR SEPTIC TANK CONTRACTING HEALTH Dw Fla"&deet ofM=M hereby cmVa the btu or m*gyred below hays sa ftW the requ of Part Lq Chaff 489,Florida�,�br septic t�k c�dardbtg avidhc�r beer aTirly Eby the DeFm tv pmvlde septic tcs�k cav�lnacting servuxs ewder the rmme o,� . ALFONSO SEPTIC CONTRACTOR INC QoWffAWConU%ftr JM IMLANM SA0171957 May 1,2017 March 31,2019 a thodzedon Number Date Issaed Eamon Date ® DATE(MM/DD/YWY) AcoR® CERTIFICATE OF LIABILITY INSURANCE 5/26/2017 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 REPkESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If 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 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 CONTACT NAME: ADVANTAGE INSURANCE OF AMERICA PHONE (305) 649-5566 FAX ADVANTAGE 649-5559 A/C No Ext 4520 NW 7th St E-MAIL SS:Jackiebatista 749@hotmail.com Miami, FL 33126 INSURER(S) AFFORDING COVERAGE NAICIJ INSURER A GRANADA INSURANCE COMPANY INSURED ALFONSO SEPTIC CONTRACTOR INC INSURER B. INSURER C 1391 W 36 ST INSURER D HIALEAH, FL 33012 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 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. 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 TYPE OF INSURANCE ADDL SUBR I POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MWDD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,O00,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 10,000 CLAIMS-MADE CI OCCUR MED EXP(Any one person) $ 5,000 GL170470 04/12/17 04/12/18 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ X POLICY JE LOCCOMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY Ea accident) ccident $ ANYAUTO BODILY INJURY(Per person) 1$ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS DAMAGE I R PER HIRED AUTOS AUTOS NON-OWNED Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIARCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNERIEXECUTIVE CI N/A E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE-EA EMPLOYE•$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) ***SEPTIC TANK SYSTEMS CLEANING,INSTALLATION,SERVICING AND REPAIR*** I I i CERTIFICATE HOLDER CANCELLATION SHOULD A F THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPI TON DATE THEREOF, NOTICE WILL BE DELIVERED IN 10050 NE 2nd ave ACCORDA CE,IWITH THE POLICY PROVISIONS. Miami Shores F1 33138 AUTHO Z D/:REENTATIVE � d` © 988-2010 ACORD CORPORATION. All rights reserved. ACORD25(2010/05) The ACORD name and logo are registered arks of ACORD og � .��vwvs . JEFF ATWATER CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS'COMPENSATION **CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS'COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers'Compensation law. EFFECTIVE DATE: 6/7/2017 EXPIRATION DATE: 6/7/2019 PERSON: BOLANOS JOSE R FEIN: 821116886 BUSINESS NAME AND ADDRESS: ALFONSO SEPTIC CONTRACTOR INC. 1391 WEST 36 STREET , H IALEAH FL 33012 SCOPE OF BUSINESS OR TRADE: Plumbing NOC and Drivers IMPORTANT:Pursuant to Chapter 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter.Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609 i r STATE OF FLORIDA PERMIT #: 13-SM-1728217 DEPARTMENT OF HEALTH APPLICATION #: AP1268305 r ONSITE SEWAGE TREATMENT AND DISPOSAL DATE PAID: SYSTEM FEE PAID: CONSTRUCTION PERMIT RECEIPT #• DOCUMENT #: PR1042936 CONSTRUCTION PERMIT FOR: OSTDS Abandonment APPLICANT: (JWHB MGMT CORP) PROPERTY ADDRESS: 899 NE 92 St Miami, FL 33138 LOT: 2 BLOCK: 1 SUBDIVISION: Golden Gate Park Addn [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] PROPERTY ID #: 11-3206-005-0020 [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 [ ] GALLONS j GPD CAPACITY A [ ] GALLONS / GPD CAPACITY N [ ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] D [ ] SQUARE FEET SYSTEM R [ ] SQUARE FEET SYSTEM A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [ ] BED [ ] N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE [ ] [ / ] [ ABOVE/BELOW]BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE [ l [ / ] [ ABOVE/BELOW]BENCHMARK/REFERENCE POINT L D FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: [ ] INCHES O Have the tank abandoned in accordance with the following procedures:(a)The tank shall be pumped out.(b)The bottom of the tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water,and(c)The T tank shall be filled with clean sand or other suitable material,and completely covered with soil.Have the system inspected H by the health department after it has been pumped and ruptured but before it is filled with sand and covered. E R SPECIFICATIONS BY: TITLE: v9�k APPROVED BY: TITLE: Engineering Specialist I �� D de CHD r an ® sca j DATE ISSUED: 12/22/2016 F�o03/22/2017 DH 4016, 08/09 (Obsoletes all previous editions which may not be usedIncorporated: 64E-6.003, FAC Page 1 of 3 NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. Such proceedings are governed by Rule 28-106, Florida Administrative Code. A petition for administrative hearing must be in writing and must be received by the Agency Clerk for the Department, within twenty-one (21) days from the receipt of this order. The address of the Agency Clerk is 4052 Bald Cypress Way, BIN A-02, Tallahassee, Florida 32399. The Agency Clerk's facsimile number is 850-413-8743. Mediation is not available as an alternative remedy. Your failure to submit a petition for hearing within 21 days from receipt of this order will constitute a waiver of your right to an administrative hearing, and this order shall become a'final order'. Should this order become a final order, a parry who is adversely affected by it is entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings may be commenced by filing one copy of a Notice of Appeal with the Agency Clerk of the Department of Health and a second copy, accompanied by the filing fees required by law,with the Court of Appeal in the appropriate District Court. The notice must be filed within 30 days of rendition of the final order. APPLICATION #:AP1268305 STATE OF FLORIDA PERMIT #:13-SM-1728217 DEPARTMENT OF HEALTH DOCUMENT #:F11089645 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM12/22/2016 CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID: FEE PAID:80.00 RECEIPT #:13-PID-3160954 APPLICANT: JWHB MGMT CORP AGENT: DAY AND NIGHT PROPERTY ADDRESS: 899 NE 92 St Miami, FL 33138 LOT: 2 BLOCK: 1 SUBDIVISION: Golden Gate Park Addn ID#: 11-3206-005-0020 CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. TANK INSTALLATION SETBACKS [ ] [011 TANK SIZE [1] [2] [ 1 [27] SURFACE WATER FT [ ] [02] TANK MATERIAL [ ] [28] DITCHES FT [ ] [03] OUTLET DEVICE [ J [29] PRIVATE WELLS FT [ ] [04] MULTI-CHAMBERED [ Y / N ] [ 1 [30] PUBLIC WELLS FT [ ] [051 OUTLET FILTER [ ] [31] IRRIGATION WELLS FT [ ] [06] LEGEND 1. 2. [ ] [32] POTABLE WATER FT [ J [07] WATERTIGHT [ ] [33] BUILDING FOUNDATIONS FT I ] [08] LEVEL [ ] [341 PROPERTY LINES FT [ ] [09] DEPTH TO LID [ ] [35] OTHER FT DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM [ ] [101 AREA [1] [21 SQFT [ ] [36] DRAINFIELD COVER [ ] [11] DISTRIBUTION BOX HEADER [ ] [37] SHOULDERS [ ] [12] NUMBER OF DRAINLINES 1, 2. [ ] [381 SLOPES [ ] [13] DRAINLINE SEPARATION [ ] [39] STABILIZATION [ ] [141 DRAINLINE SLOPE [ ] [15] DEPTH OF COVER ADDITIONAL INFORMATION [ ] [16] ELEVATION [ ABOVE / BELOW ]BM [ ] [40] UNOBSTRUCTED AREA [ ] [17] SYSTEM LOCATION [ ] [41] STORMWATER RUNOFF [ ] [18] DOSING PUMPS [ ] [42] AVMS [ ] [19] AGGREGATE SIZE L ] [43] MAINTENANCE AGREEMENT [ ] [20] AGGREGATE EXCESSIVE FINES [ ] [441 BUILDING AREA [ ] [21] AGGREGATE DEPTH [ ] [45] LOCATION CONFORMS WITH SITE PLAN FILL / EXCAVATION MATERIAL [ ] [46] FINAL SITE GRADING [ 1 [221 FILL AMOUNT [ ] [47] CONTRACTOR [ ] [231 FILL TEXTURE [ ] [48] OTHER [ ] [24] EXCAVATION DEPTH ABANDONMENT [ ] [25] AREA REPLACED [ ] [49] TANK PUMPED 12/20/2016 [ ] [26] REPLACEMENT MATERIAL [ ] [501 TANK CRUSHED & FILLED 12/20/2016 Comments: [ APPROVED / �, a DATE: 12/29/2016 DISAPPROVED ]' Engineering Specialist 11 Erlande Omisca(De I e x CONSTRUCTION FINAL SYSTEM [ APPROVED / DISAPPROVED ]: D : 12/29/2016 ENGINEERING SPECIALIST I Yvenel Clermont(Fip en (Explanation of violations on following page) ``T� DH 4016, 08/09 (Obsoletes all previous editions which may not be Incorporated: 64E-6.003, FAC Page 2 of 3 EH Database v 1.0A AP1268305 EID1728 APPLICATION #:AP1268305 STATE OF FLORIDA PENT #:13-SM-1728217 ' DEPARTMENT OF HEALTH DOCUMENT #:FI1089645 ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM 12/22/2016 ' CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:p FEE PAID-80.00 RECEIPT #:13-PID-3160954 Violation Number Comment DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Page 2 of 3 Incorporated: 64E-6.003, FAC EH Database v 1.0.1 AP1268305 EID1728217 J.. 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BOX 623271 SOUTH TLORIDA..•FL. 33082-327I (303) 772-0766 SIyOLL Ii OhM E ��1Nt1�O ff/31V1S PJe' 1 r no a� 93y s7or 'ItlLi3 3ws 1d30 J4.18 4" Q � ld3a ONINOZ 7 JL 6 8 4 3 2 I14 oda Ike a3.not�d� 7 a6 I!n saa:J�aS iw�iW _ 1SA "# 8 '3d lo 13 I�4dr � N 13.$y \ tvy 4,Yt N LOCATION SKETCH NOT TO SCALE LEGAL DESCRIPTION Lot 1 & the East2 of Lot 2 in Block 1 of GOLDEN GATE PARK ADDITION, according to the plat thereof, as' recorded in Plat Book 6 at Page 130 of the Public Records of Miami-Dade County, Florida. \ SURVEYORS NOTES: 1.9s 1 ) . Legal description provided by client. •, � 2) . Only record plat easements are shown. ��3�.. 3) . Right of way information obtained from record pJ&t. a ��.•• 4) . In Federal Flood Zone X, Panel 0093 last revised 3-2-94. �: �; . , •••• •••••• 5) . Benchmark used- Dade County Benchmark #B-62. ti � � �, •. • ."�•• • *Does* 6) . Elevations are referenced to National Geodetic Vertical Datum' 03 1929 Adjustment (NGVD29) . 3P \ ti H •�M•00 •••• "•••' ' • OLP° /�,p�j' .9 /(o•uL � r`r� 7« I+K l4h 1¢.UQ.• : , •••••• ••i••• " as • ( •0900• �� \• _.r • 0000 •. • • • . • • • • • 0000•• 0000•• - • • • • • • • • ••,; 00.00 • • voll 1� • P/Pr' FD. FOSEPH DARY, IMPROVEMENTS & ELEVATION SURVEY Jimes Wahl 899 N.E. 92 St. Miami Shores, F1. 33138 6 NO?a. " �7GT VALID QHLBSB SEJILYD NiTQ 3N iPIBOam SOavvo" SUL.• � cg /�.7J S w� -? ERTIFY TUT T81 SDBVZr B8PE2SENTzD HE110M COMM MITH 481 CHMAL STANDrBDS ADOPTID BY THE FLORIDA BOA1D of S=VEY01s no COAPTSa OC1 i7St FLOHIDA ADHIHIS'l'7t71T2VE CSE. POl3DRJUfT TO• 1 2.027, Florida 9Wtntta• JIVISIONS BY DATE P7SH L. MARTIN PROFESSIONAL LANG SURVEIPOR*4368 wAm11Y 3G" DATE P0. X840 T ISrA TS OF FLOR10A Ur �c=ZIT 2-2 6-OI -- Zc►�S—(oe3o -• .e•_.�� _ m