PL-17-1254Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Permit
Permit NO. PL -5-17-1254
Permit Type: Plumbing - Residential
Work Classification: Septic
Permit Status: APPROVED
Issue Date: 8/11/2017
Expiration: 02/07/2018
Parcel Number
Applicant
436 NE 94 Street
Miami Shores, FL 33138-
1132060140340
Block: Lot:
JASON DOMARK
Owner Information
Address
Phone
CeII
JASON DOMARK
436 NE 94 Street
MIAMI SHORES FL 33138-
(305)726-7147
Contractor(s) Phone
SOUTHERN SEPTIC CONTRACTORS I (305)598-8266
CeII Phone
Valuation:
Total Sq Feet:
$ 2,000.00
0
Type of Work: SEPTIC TANK
Type of Piping:
Additional Info:
Bond Return :
Classification: Residential
Scanning: 3
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Notary Fee
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$1.20
$4.50
$4.50
$0.40
$5.00
$300.00
$9.00
$1.60
$326.20
Pay Date Pay Type
Invoice # PL -5-17-63943
05/08/2017 Credit Card $ 50.00 $ 276.20
08/11/2017 Check #: 670 $ 276.20 $ 0.00
Amt Paid Amt Due
Available Inspections:
Inspection Type:
HRS Approval
Final
Review Plumbing
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 certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction aryelj zoning. Futhermore, I authorize the above-named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent
Building Department Copy
August 11, 2017
Date
August 11, 2017 1
\e_v
vJ\�
BUILDING
PERMIT APPLICATION
BUILDING fl ELECTRIC
❑■ PLUMBING ❑ MECHANICAL
JOB ADDRESS: 436 NE 94 ST
City: Miami Shores
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
Master Permit No.
❑ ROOFING ❑ REVISION
RECEIVED
MAY - 8 2017
,Sfl
FBC 20Q)
P125u
Sub Permit No.
❑ EXTENSION 0RENEWAL
❑ CANCELLATION ❑ SHOP
DRAWINGS
PUBLIC WORKS ❑ CHANGE OF
CONTRACTOR
County:
Miami Dade Zip:
Folio/Parcel#: 11-3206-014-0340
Occupancy Type:
Load: Construction Type:
Is the Building Historically Designated: Yes
Flood Zone:
OWNER: Name (Fee Simple Titleholder): JASON DOMARK
Address:436 NE 94 ST
City: MIAMI SHORESState: FL
Tenant/Lessee Name: N/A
Email:
NO X
BFE: FFE:
Phone#: 305 795-2204
Zip: 33138
Phone#:
CONTRACTOR: Company Name: SOUTHERN SEPTIC
Address: 21051 SW 234 ST
Phone#: 305 598-8266
City: HOMESTEAD State: FL
Qualifier Name: ROBERTO RODRIGUEZ
State Certification or Registration #: SR 0021421
DESIGNER: Architect/Engineer: N/A
Zip: 33031
Phone#: 305 598-8266
Certificate of Competency #:
Phone#:
State: Zip:
Address: City:
Value of Work for this Permit: $ Square/Linear Footage of Work:
Type of Work: ❑ Addition ❑ Alteration ❑ New 0 Repair/Replace ❑ Demolition
Description of Work: RENEWAL OF SEPTIC AND DRAIN FIELD PERMIT.
pciL Pi IU -120 .
Specify color of color thru tile:
Submittal Fee $ –�JE rmit Fee $ ` '1 J CCF $ ( -i 2_ CO/CC $ �—
L
Scanning Fee $ Radon Fee $ - S 6 DBPR $ L1 -SO
c71 -
Technology Fee $ % • COO
Structural Reviews $
(Revised02/24/2014)
Training/Education Fee $
Notary $
Double Fee $
Bond $
TOTAL FEE NOW DUE $ �_ T VJ • w
Bonding Company's Name (if applicable) N/A
Bonding Company's Address
City State Zip
Mortgage Lender's Name (if applicable) N/A
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 isissued. In the absence of such posted notice, the
inspection will not be approved and a reinspection fee will be charged.
Signature
OWNER or AGENT •
The foregoing instrumentpwas acknowledged before me this
.4)‘
day of I" ilk/N , 20 11 , by
`jC.SDIA IiKv(, who is.personally known to
me,.or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
((o I?C4
:•: ...... SANDY L. GOODRICH
.t s MY COMMISSION 0 FF 091204
.. �� EXPIRES: March 30, 2018
Bonded Thru Notary Public Underwriters
i
Signature
CONTRACTOR
The foregoing instr
6* day of
' .s acknowle
me or who has produced
ged before me this
,, 20 , by
tt
-nn - `tNis personally known to
Z 2-0 -se
identification and who did take an oath.410"c3 I I -1 -cg
NOTARY PUBLIC:
Sign:
Print:
Seal:
MY COMMISSION # GG 044602
I
Fo: Fro . Bonded Thru Notary Public Underwriters
***********************************************************Vs* ***********************************************
APPROVED BY
(Revised02/24/2014)
Plans Examiner
Structural. Review
Zoning
Clerk
Miami Shores Village
Building Department
10050 NE 2 Ave, Miami Shores, FI 33138
Tel: (305)795-2204 • Fax; (305)756-8972
10/21/2016
To: Current Owner
436 NE 94 Street
Miami Shores, FL 33138 -
Permit: PL -6-14-1208
Address: 436 NE 94 Street Miami Shores FL33138-
Dear Sir or Madam,
Our records indicate that the above referenced permit has expired without obtaining the
proper final inspection. In order to serve you better, we need to keep our files up to date.
As per section 105.4.1 of the Florida Building Code, "Every permit issued shall become invalid
(expired) unless the work authorized by such permit is commenced within six months after its
issuance, or if the work authorized by such permit is suspended or abandoned for a period of
six months after the work is commenced, or completed without obtaining the final inspection
of the work performed.."
Please be advised that open permits will hinder your ability to obtain new permits, refinance or
sell this property.
Please contact the Building Department, within 15 days of receipt of this letter in order to take
care of this matter.
Sincerely,
(-DM
Ismael Naranjo (CB
Building Director
��t� -\2S4-
APPLICATION # : API 149266
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL A F ROI
APPLICANT: Richard Gordon
AGENT: Southern Septic
PROPERTY ADDRESS:
LOT: 8
SUBDIVISION:
PERMIT # :13 -SC -1542513
DOCUMENT # : FI958944
DATE PAID: 06/04/2014
FEE PAID :200.00
DEC 01 2011 RECEIPT #:13 -PID -2414924
436 NE 94 St
Q/liami, FL 33138
BLOCK:
51
ID#: 11-3206-014-0340
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION
[01]
[02]
[03]
[04]
[05]
[06]
[07]
[08]
[09]
TANK SIZE [1] 1050.00
TANK MATERIAL
OUTLET DEVICE
MULTI-CHAMBERED
OUTLET FILTER
[2]
Concrete
Y
Polylok
/ N
LEGEND 1. 13-076-08DC3 2.
WATERTIGHT
LEVEL
DEPTH TO LID
DRAINFIELD INSTALLATION
[10)
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
AREA [1] r 468 [2]
DISTRIBUTION BOX
NUMBER OF DRAINLINES
DRAINLINE SEPARATION
DRAINLINE SLOPE
DEPTH OF COVER
ELEVATION [ ABOVE /
SYSTEM LOCATION
DOSING PUMPS
SQFT
HEADER X
1. 6.00 2.
BELOW
IBM 32.64
AGGREGATE SIZE
AGGREGATE EXCESSIVE FINES
AGGREGATE DEPTH
FILL / EXCAVATION MATERIAL
[22] FILL AMOUNT
[23] FILL TEXTURE
[24] EXCAVATION DEPTH
[25] AREA REPLACED
[26] REPLACEMENT MATERIAL
Comments: Comments are on page 2.
[
['
SETBACKS
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
SURFACE
DITCHES
PRIVATE
WATER FT
FT
WELLS FT
PUBLIC WELLS FT
IRRIGATION WELLS FT
POTABLE WATER 50 FT
BUILDING FOUNDATIONS
PROPERTY LINES
OTHER
FILLED / MOUND SYSTEM
[36]
[37]
[38]
[39]
5 FT
5 FT
FT
DRAINFIELD COVER
SHOULDERS
SLOPES
STABILIZATION
ADDITIONAL INFORMATION
[40] UNOBSTRUCTED AREA
[41] STORMWATER RUNOFF
[42] ALARMS
[43] MAINTENANCE AGREEMENT
[44] BUILDING AREA
[45] LOCATION CONFORMS WITH SITE PLAN
[46] FINAL SITE GRADING
[47] CONTRACTOR Roberto Rodriguez (Southern
[48] OTHER INFILTRATOR Quick4 Plus EQ36 LP
ABANDONMENT
[49] TANK PUMPED 06/18/2014
[50] TANK CRUSHED & FILLED 06/18/2014
CONSTRUCTION
FINAL SYSTEM
[
APPROVED
APPROVED
/ /7' 1: \ '77r,n Dade CHD DATE : 06/18/2014
DI SAP PROVED ] • Engineer Specialist II Jcialph 13 f?ivergeripepartment of Health in Dade
Florida Health mit mi -Dade Coupgide
t of Health in Dade
/ DISAPPROVED 3:
(Explanation of Violations on following page)
Engineer Speer lit
CHD DATE : 06/18/2014
DH 4016, 08/09 (Obsoletes all previous editions wh;ch may notbe us
Incorporated: 64E-6.003, FAC
EH Database v 1.0.1
API149266
EID1542513
Page 2 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
!fir' ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL
APPLICATION # : API 149266
PERMIT #: 13 -SC -1542513
DOCUMENT #:F1958944
DATE PAID:06/04/2014
FEE PAID:200.00
RECEIPT #:13 -PID -2414924
Violation Number
Comment
Comments
36 Low Profile Quick -4 DF; Polylok PL -68 outlet filter.
The system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of 400
gpd.
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC
EH Database v 1.0.1
AP1149266
EID1542513
Page 2 of 3
oRi\-0
611\
BUILDING
PERMIT APPLICATION
0BUILDING ELECTRIC
Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795-2204 Fax: (305) 756-8972
INSPECTION LINE PHONE NUMBER: (305) 762-4949
ROOFING
XPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS
JOB ADDRESS: LI3 CI rN &rfl i -
Master Permit No.
Sub Permit No.
.JUN 10 2014
FBC 20
12e
❑ REVISION ❑ EXTENSION []RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores ` 1` County:
—'
Folio/Parcel#: I ' 2 U° ' O I,M b �3D
Occupancy Type: SW_ Load: Construction Type:
OWNER: Name (Fee Simple Titleholder): 3-Pc5,04.1 1tk i,AQv(-
Miami Dade Zip: 33i39)
Is the Building Historically Designated: Yes NO A
Address: 436 N6 9kf. .'r
City: iyh,S1i�1u.S State: Ti-
Flood Zone:
BFE: FFE:
Phone#:
Zip: -736
Tenant/Lessee Name: "hone#: ;c05 -7Z6— 7117
Email: .S0.So.yDcrylgp✓_ uPr femAit.,Cor\
CONTRACTOR: Company Name: Scu tl%9Y r S
Address:
City: M t k !-t 11. State:
b (r
Qualifier Name: Zea�ID
"2/ I Stu 1 S3 7A7 N
State Certification or Registration #:
DESIGNER: Architect/Engineer:
Address:
Value of Work for this Permit: $
Type of Work: ❑ Addition
Description of Work:
Phone#: 3 Oa 51 8-1 z6.4.
Zip: 5 3 1q M
Swig -82,14
Phone#:
Certificate of Competency #:
Phone#:
City: State: Zip:
Square/Linear Footage of Work:
❑ Alteration ❑ New
Repair/Replace
❑ Demolition
5e046 -1-6114k. 'Pep/ace by1%
Specify color of color thru tile:
Submittal Fee $ 'ol° Permit Fee $ Yr3W Y CCF $ CO/CC $
i
Scanning Fee $ Radon Fee $ DBPR $ Notary $
Technology Fee $ Training/Education Fee $ Double Fee $
Structural Reviews $ Bond $
TOTAL FEE NOW DUE $
(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 01(2.b
OWNER or AGENT
The foregoing instrument was acknowledged before me this
q� . r
dayof�C�� , 20 � �-i , by
. r►+ri) , who is personally known to
me or who has produced — as
identification and who did take an oath.
NOTARY PUBLIC:
SUSAN KING
.1 My Comm. Expires Dec 16, 2016
tes* Commission # EE 858688
BY%,°J
APPROV ' '
E� Bonded Through National Notary ecgn
(Revised02/24/2014)
Signature
The foregoing instrument was acknowledged before me this
day of , 20 Ire1 , by
�YL�I `a—k-r;-?roho is personally known to
me or who has produced�I as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal:
_•-/ery v
•.,n c/ �
•
,"i// S/Ua 10.
a 1
Plans Examiner
Structural Review
Zoning
Clerk
Prepared by and return to:
Jeffrey S. Hersh, Esq.
Jeffrey S. Hersh, P.A.
1666 Kennedy Causeway Suite 412
North Bay Village, FL 33141
305-866-1110
File Number: 527.0002
Will Call No.:
Parcel Identification No. 11-3206-014-0340
[Spix Above This Line For Recording Data]
Warranty Deed
(STATUTORY FORM - SECTION 689.02, F.S.)
This Indenture made this Z8 day of hetli- , 2014, between Richard Gordon Coming, a single man, and John
Francis Lally, a single man, whose post office address is 1008 Sharpless Road, Melrose Park, PA 19027 of the County of
Montgomery, State of Pennsylvania, grantor*, and Jason Ryan Domark and Rachel Heron Inman Domark, husband
and wife, whose post office address is 436 Northeast 94 Street, Miami Shores, FL 33138 of the County of Miami -Dade,
State of Florida, grantee*,
Witnesseth, that said grantor, for and in consideration of the sum of TEN AND NO/100 DOLLARS ($10,00) and other
good and valuable considerations to said grantor in hand paid by said grantee, the receipt whereof is hereby acknowledged,
has granted, bargained, and sold to the said grantee, and grantee's hens and assigns forever, the following described land,
situate, lying and being in Miami -Dade County, Florida, to -wit:
Lot 8, in Block 51, MIAMI SHORES SECTION 2, according to the Plat thereof, as recorded in Plat
Book 10, at Page 37, of the Public Records of Miami -Dade County, Florida.
Subject to taxes for 2014, and subsequent yeara; covenants, conditions, restrictions, easements,
reservations and limitations of record, if any.
and said grantor does hereby fully warrant the title to said land, and will defend the same against lawful claims of all persons
whomsoever.
* 'Grantor and 'Grantee' are used for singular or plural, as context requires.
In Witness Whereof, grantor has hereunto set grantor's hand and seal the day and year first above written.
Signed, sealed and delivered in our presence:
Seal)
State of Florida
County of Miami -Dade
The foregoing instrument was acknowledged before me this Z€ day of AM-) t- , 2014 by Richard Gordon
Coming and John Francis Lally, who u are personally known or [X] have produced a driver's license as identification.
[Notary Seal]
wu.. Jeffrey S. Hersh
�.= ptPIRES JUL08,2014
Sig N,1 www.gpeonNorNNoxit
Notary Pub
Printed N
3f Fit, • tea d -
My Commission Expires:
41412.01y
•
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Richard Gordon
' b
:G3 IE s4m =f
PERMIT it: 13 -SC -1542513
APPLICATION # : AP 1149266
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR941636
PROPERTY ADDRESS: 436 NE 94 St Miami, FL 33138
LOT: 8
BLOCK: 51 SUBDIVISION:
PROPERTY ID 0: 11-3206-014-0340
[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
WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT
PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
MATERIAL FACTS,
TO MODIFY THE
NULL AND VOID.
OTHER FEDERAL,
SYSTEM DESIGN AND SPECIFICATIONS
T [
A [
N [
K [
1,050 ] GALLONS / GPD New Septic Tank CAPACITY
0 ] GALLONS / GPD CAPACITY
0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ]
D [ 300 ] SQUARE FEET bed configuration SYSTEM
R [ 0 ] SQUARE FEET SYSTEM
A TYPE SYSTEM:
I CONFIGURATION:
N
F LOCATION OF BENCHMARK:
[x] STANDARD
[ ] TRENCH
[ ] FILLED [ ] MOUND
[x] BED [ ]
CL NE 94 st., 9.77' NGVD
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D FILL REQUIRED: [ 0.00] INCHES
0
T
H
E
[ 0.72 ] [I Ivens Y
[ 35.28 ] 4 INCHES
FT ][I ABOVE If BELOW ] BENCHMARK/REFERENCE POINT
FT 1[ABOVE 4 BELOW 1 BENCHMARK/REFERENCE POINT
EXCAVATION REQUIRED:
[ 48.00 ] INCHES
New sewer line shall be permitted and inspected by the pertinent plumbing dept.
Inspector to verify the existing septic tank is properly abandoned before final approval.
*Invert elevation of drainfield to be no less than 7.33' NGVD.
*Bottom of drainfield elevation to be no less than 6.83' NGVD.
*Install 12" of slightly limited soil under the bottom of drainfield.
-Perimeter of excavation area shall be at least 2 ft. wider and I• ger than the proposed absorption bed or drain trench.
The system is sized for 3 bedrooms with a maximum occu
r
cy of 6 persons (2 per bedroom), for a total estimated flow
SPECIFICATIONS BY:
APPROVED BY:
DATE ISSUED:
DE 4016, 08/09
Incorporated:
TITLE:
TITLE:
Dade
c �3S caza
06/•. '14 EXPIRATION DATE:
(Obsoletes
64E-6.003,
all previous editions which may not be used)
FAC
The 40rtiaofor (or designee) is rr$g perform a
soil boring adjacent to the drainfield excavation at the
time of final inspection. Prior to Final Approval, the OOH
inspector shall witness the soil boring and compare the
results to the original site evaluation submitted. A
reinspection fee will be assessed if the contractor is not
at the jobsite the arranged time.
SE930546
09/04/2014
CBD
Page 1 of 3
DOCUMENT #: PR941636
Required drainfield area based on rule 64E -6.015(6)(c)2.
Install a new drainfield to achieve Drainfield size requirement.
The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s.
64E -6.013(3)(f), FAC.
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 # A02, Tallahassee, Florida 32399-1703. The
Agency Clerk's facsimile number is 850-410-1448.
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 party who is adversely affected by it is
entitled to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedings
are govemed 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.
• ` STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION .FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit Application Number
PART I1- SITEPLAN
Scale: Each block represents 10 feet and 1 inch = 40 feet. Fe
6.
INEMPIMMINIMI
t
i
<6•Cla
roptscrot
t o
5
a.�
T
s/T o1 t )
toS
C gv6A m oO1N O
'
•
?4»."-
9l
•
NC
Notes:
THERE ARE NO PERTINENT FEATURES ON ADJACENT PROPERTIES AND OR ACROSS
THE STREET THAT MAY AFFECT THE NEW SYSTEM INSTALLATION,
Site Plan submitted by:
Plan Approved
By
No Approved
SRoa2�y2�
Date
County Health Department
ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT
DH 4015,10196 (Replaces HRS -H Form 4016 which may be used)
(Stock Number. 5744-002-4015-6)
Page 2 of 4