PL-18-437 }
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795-2204 Fax: (305)756-8972
Inspection Number: INSP-308336 Permit Number: PL-2-18-437
Scheduled Inspection Date: July 16, 2018 Permit Type: Plumbing - Residential
Inspector: Massanet, Maykel Inspection Type: Final
Owner: REBELO,ALEJANDRO Work Classification: Septic
I
Job Address:353 NE 94 Street-
Miami Shores, FL 33138- Phone Number
Parcel Number 1132060136110
Project: <NONE>
i
Contractor: A AMERICAN SEPTIC& PLUMBING Phone: (305)866-5600
Building Department Comments
REPLACE SEPTIC TANK AND DRAIN FIELD Infractio Passed Comments
INSPECTOR COMMENTS False
TO REPLACE PL13-1350
Inspector Comments
Passed �,/ CREATED AS REINSPECTION FOR INSP-297736. HRS APPROVAL ON
FILE
5/14/18 NO GRASS PLACED.
Failed
Correction s
Needed
Re-Inspection (�
Fee 1 I
No Additional Inspections can be scheduled until
reinspection fee is paid.
f
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July 13, 2018 For Inspections please call: (305)762-4949 Page 18 of 26
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��►.� DIVISIONt1F
EnvironmentaA ath
Florida Health
Miami-Dade County
OSTDS/Well Division =
11805 SW 26th Street Miami, FL 33175
Inspector MC4 r Date - .K
4.
dressti
5'71' OSTDS #
,ry
Comments. d@
AMW 'Alk
S ign�tu�re ,. ,, ► s—
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Permit NO. PL-2-l'"37
Miami Shores VillagePermit Type:Plumbing-Residential
10050 N.E.2nd Avenue NE Work Classification. Septic
Miami Shores,FL 33138-0000 Per, it
Phone: (305)795-2204 Penrlit Status:APPROVED
R'C01'tiDp'
Issue Date:2/27/2018 Expiration: 08/26/2018
Project Address Parcel Number Applicant
353 NE 94 Street 1132060136110
i ALEJANDRO REBELO
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
ALEJANDRO REBELO 353 NE 94 Street
MIAMI SHORES FL 33138-
353 NE 94 Street t
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 2,450.00
A AMERICAN SEPTIC&PLUMBING (305)866-5600 (786)236-5599
�- - � Total Sq Feet: 150
Type of Work:TANK AND DRAIN Available Inspections:
Type of Piping: Inspection Type:
Additional Info: HRS Approval
Bond Return: Final
Classification:Residential Scanning: 1 Review Plumbing
a
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.00
DBPR Fee Invoke# PL-2-18-66509
DCA Fee $0.00 02/20/2018 Cash $50.00 $ 108.00
Education Surcharge $0.00 02/27/2018 Check#: 1405 $ 108.00 $0.00
Notary Fee $5.00
Permit Fee $150.00
Scanning Fee $3.00
Technology Fee $0.00
Total: $158.00
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 andzoning. Futhermore,I authoriz ve-nneeticontractor to do the work stated.
February 27, 2018
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
February 27, 2018 1
� Y� - �3 G- s'3"� �
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Miami Shores Village
w�-� , 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 /� 1
FB�C/20
BUILDING Master Permit No. I?L
lv —1 3 •—_.135
"PERMIT APPLICATION Sub Permit No.pl
,.❑BUILDING _❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION QRENEWAL
QPLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
j CONTRACTOR DRAWINGS
JOB ADDRESS: 353 NE 94 Street
City: Miami Shores County: Miami Dade Zip:
Folio/Parcel#:11-3206-013-6110 Is the Building Historically Designated:Yes NO X
Occupancy Type: R Load: Construction Type: Repair Flood Zone: N BFE: N FFE: 13.10
OWNER:Name(Fee Simple Titleholder):Cesar Garcia Phone#:
Address:353 NE 94 St
City: Miami Shores state: FL Zip: 33138
Tenant/Lessee Name. NA Phone#:
Email:
CONTRACTOR:Company Name: A American Septic and Plumbing, Inc Phone#: 3058665600
Address: 12555 Biscayne Blvd #970
City: Miami state FL Zip: 33181
Qualifier Name: William Mark Woodard Phone#: 7862365599
State Certification or Registration#: SEP000947 Certificate of Competency#: SA0000947
DESIGNER:Architect/Engineer: NA Phone#:
Address: City: State: Zip:
Value of Work for this Permit:$0 Square/Linear Footage of Work: 0
r Type of Work: El Addition El Alteration ❑ New Q Repair/Replace ❑ Demolition
Description of Work: Reopen to close 2013 drain field repair permits
AP1110445 and AP1110447
Specify color of color thru tile:
Submittal Fee$ Permit Fee$JS . CCF$ CO/CC$
Scanning Fee$ 3. G1 Radon Fee$ DBPR$ Notary$
! Technology Fee$ Training/Education Fee$ Double Fee$
Structural Reviews$ Bond$
TOTAL FEE NOW DUE$
(Revised02/24/2014)
k
4
i
Bonding Company's Name(if applicable) / �(
Bonding Company's Address
i
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.....
F
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 r o ur se days after the building permit is issued. In the absence of such posted notice, the
inspection will not blapprbv an ei ection fe be charged.
! I-
Signature/ Signatur -
OWNER rAGENT NTRACTOR t
The foregoing instrument was acknowledged before me this The foregoing instrum nt was acknowledged befirerthis
��day of_ 20
by day of 20 by
6 SO Ir I -1 �QVrP w1a is'pQn�y nown to W lAi 1t1 W06 who is pPrcoually known to
me or who has produced jr1�as me or who has produced as
identification and who did take an oath. identification and who did take an oath.
NOTAIR C: NOTARY PUBLIC:
E
Sign: Sign:
Print: MA=Nob�rG2,,
nt•
MY CO2 rote B�i� BARBARAZEEMAN
Seal: "'• :o EXPIRal: * *MY COMMISSION#AG 061186
,- P` Bonded l hers N.� a= EXPIRES:February 16,2021
FO/;�Q.•
4''OF F��Q`Bonded Toru Budget Nolery Waits
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APPROVED BY ;"/-- Plans Examiner Zoning
Structural Review Clerk
(RevisedO2/24/2014)
i
2/20/2018 Property Search Application-Miami-Dade County
"ROPER"T A"'PRAISER
OFFICE OF THE V I F
mA
` Y
Summary Report
Generated On:2/20/2018
-._7 _ -
Property Information n
Folio:
11-3206-013-6110
353 NE 94 ST
Property Address: "
Miami Shores,FL 33138-2831
f
Owner JENNIFER ELISABETH GARCIA o
CESAR MANUEL GARCIA
353 NE 94 ST
Mailing Address MIAMI SHORES,FL 33138 USA '
PA Primary Zone 1100 SGL FAMILY-2301-2500 SQ
0101 RESIDENTIAL-SINGLE
Primary Land Use FAMILY: 1 UNIT
Beds/Baths/Half 3/2/0
Floors 1
Living Units 1 �
r,
Actual Area 2,892 Sq.Ft ,
Living Area 2,758 Sq.Ft
Adjusted Area 2,710 Sq.Ft Taxable Value Information
Lot Size 13,660 Sq.Ft 2017 2016 2015
Year Built 1951 County '
Assessment Information Exemption Value 1 $50,000 I $50,000 $50,000
Year 2017 2016 2015Taxable Value $411,764 $402,267 $399,124
Land Value $409,800 $341,500 $327,840 School Board
Exemption Value $25,000 $25,000 $25,000
Building Value $188,616 $188,616 $188,616
XF Value $39,196 $39,588 $25,400
Taxable Value $436,764 $427,267 $424,124
City r
Market Value $637,612 $569,704 $541,856 Exemption Value 1 $50,000 $50,000 $50,000
Assessed Value $461,764 $452,267 $449,124 Taxable Value $411,764 $402,267 $399,124
Y
Benefits Information Regional
Benefit Type 2017 2016 2015 Exemption Value $50,000 $50,000 $50,000
Taxable Value 1 $411,764 $402,267 $399,124
Save Our Homes Cap Assessment Reduction $175,848 $117,437 $92,732
Homestead Exemption $25,000 $25,000 $25,000 Sales Information
Second Homestead Exemption $25,000 $25,000 $25,000 Previous Sale Price OR Book-Page Qualification Description
Note:Not all benefits are applicable to all Taxable Values(i.e.County,School 07/06/2017 $760,000 30612-0459 Qual by exam of deed
Board,City,Regional).
01/01/2007 $735,000 25311-3433 Sales which are qualified
Short Legal Description 04/01/2003 $430,000 21241-3616 Sales which are qualified
MIAMI SHORES SEC 1 AMD PB 10-70 1 02/01/1993 1 $162,000 15832-0080 Tales which are qualified
LOT 12&W20FT OF LOT 13 BLK 45
LOT SIZE SITE 13660 SQ FT
OR 21241-3616 04/2003 1
COC 25311-3433 01 2007 1
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The Office of the Property Appraiser is continually editing and updating the tax roll.This website may not reflect the most current information on record.The Property
Appraiser and Miami-Dade County assumes no liability,see full disclaimer and User Agreement at http://www.miamidade.gov/info/disclaimer.asp
Version:
ROE,
A
foe
Miami shore 's Village
0
Building Department
LORI10050 N.E.2nd Avenue
OR Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to 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 Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-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 i isu
n ra
,r 7ce coverage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BELOW' OU KNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
Owner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of
20
By( LIA per ivho is personally known to me or has produced
as identification.
NotaciaK
mv...V1 MAHARAJ K.GONZALEZ
MY COMMISSION#GG 044602
SEAL:
W, EXPIRES:November 2,2020
14�,R*,FTV Bonded Thru Notary Public Underwriters
t
SEP000947 Nkl< AMERICAN SEPTIC & PLUMBINGINC.
12555 BISCAYNE BOULEVARD#970
..
NORTH DADE(305)866-5600 NORTH MIAMI,FL 33181 BROWARD(954)922-2119
SOUTH DA DE(305)254-8600 FAX(305)8916905
X
2/20/2018
State of Florida ti
County of Dade.
Before me this day personally appeared 1I I IG m ry)G r YJ who,being duly sworn,
deposes and says:
That he or she will be the only person working on the project located at:
353 NE 94 Street Miami Shores,FL 33138
Contractor Silfhature
Sworn to(or affirmed)and subscribed before me this 2�day of r-eJ ,2018,
By i l l I Ci m Nit O r V) WCt rd.
Personally know
OR Produced Identification >4
Type of Identification Produced
MAHARAI K GONZALEZ
MY COMMISSION#GG 044602
:a= EXPIRES:November 2,2020
:�o qp••
Bonded n;n,Notary Publictlndenwriters P ' t,Type,or Stamp Name of Notary
APPLICATION #:AP1110445
STATE OF FLORIDA PERMIT #:13-SC-1478057
OKI
DEPARTMENT OF HEALTH DOCUMENT #:F1919122
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:06/0//2013
FEE PAID:200-00
RECEIPT #:13-PID-2160498
APPLICANT: Alejandro Rebelo
AGENT: A American Septic
PROPERTY ADDRESS: 353 NE 94 St Miami, FL 33138
LOT: 12 BLOCK: 45
SUBDIVISION: ID#: 11-3206-013-6110
CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED.
TANK INSTALLATION SETBACKS
[ ] [01] TANK SIZE [1] 1090.00 [2] [ ] [27] SURFACE WATER FT
[ ] [02] TANK MATERIAL Polyethylene [ ] [28] DITCHES FT
[ ] [03] OUTLET DEVICE [ ] [29] PRIVATE WELLS FT
[ ] [04] MULTI-CHAMBERED ( Y N ] [ ] [30] PUBLIC WELLS FT
[ ] [05] OUTLET FILTER Zabel [ ] [31] IRRIGATION WELLS FT
[ ] [06] LEGEND 1. 07-053-10 2. [ ] [32] POTABLE WATER 35 FT
[ ] [07] WATERTIGHT [ ] [33] BUILDING FOUNDATIONS 5 FT
[ ] [08] LEVEL [ ] [34] PROPERTY LINES 2 FT
[ ] [09] DEPTH TO LID [ ] [35] OTHER FT
DRAINFIELD INSTALLATION FILLED / MOUND SYSTEM
[ ] [10] AREA [1] 150 . [2] SQFT [ ] [36] DRAINFIELD COVER
[ ] [11] DISTRIBUTION BOX HEADER X [ ] [37] SHOULDERS
[ ] [12] NUMBER OF DRAINLINES 1. 3.00 2. [ ] [38] SLOPES #
�[ ] [13] DRAINLINE SEPARATION [ ] [39] STABILIZATION
[ ] [14] DRAINLINE SLOPE
i[ ] [15] DEPTH OF COVER ADDITIONAL INFORMATION
[ ] [16] ELEVATION [ ABOVE / BELOW ]BM 70.80 [ ] [40] UNOBSTRUCTED AREA
[ ] [17] SYSTEM LOCATION [ ] [41] STORMWATERiRUNOFF
[ ] [18] DOSING PUMPS S [ ] [42] ALARMS
[ ] [19] AGGREGATE SIZE [ ] [43] MAINTENANCE AGREEMENT
[ ] [20] AGGREGATE EXCESSIVE FINES [ ] [44] BUILDING AREA f
[ ] [21] AGGREGATE DEPTH [ ] [45] LOCATION CONFORMS WITH SITE PLAN,
FILL / EXCAVATION MATERIAL [ ] [46] FINAL SITE GRADING
[ ] [22] FILL AMOUNT [ ] [47] CONTRACTOR William Woodard(A America
[ ] [23] FILL TEXTURE [ ] [48] OTHER ADS ARC 24
[ ] [24] EXCAVATION DEPTH ABANDONMENT
[ ] [25] AREA REPLACED [ ] [49] TANK PUMPED 07/12/2013
[ ] [26] REPLACEMENT MATERIAL [ ] [50] CRUSHED 6 FILLED 07/12/2013
Comments: Comments are on page 2.
i
r
CONSTRUCTION I APPROVED / Dade CHD DATE: 07/12/2013
DISAPPROVED ' Engineer Speci II Jos h R P' rger(D a County Environmental Healt
FINAL SYSTEM [ APPROVED / DISAPPROVED ); CHD DATE: 07/12/2013
ng-meer peas Ist os r n nvironmental Hea
(Explanation of Violations on following page)
DH 4016, 08/09 (Obsoletes all previous editions whichm not be used)
Incorporated: 64E-6.003, FAC Page 2 of 3
EH Database v 1.0.1 API 110445 EID1478057
i
APPLICATION #:AP1110445
STATE OF FLORIDA PERMIT #:13-SC-1478057
DEPARTMENT OF HEALTH DOCUMENT #:F1919122
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION INSPECTION AND FINAL APPROVAL DATE PAID:06/07/2013
FEE PAID:200.00
RECEIPT #:13-PID-2160498
Violation Number Comment
Comments
The system is sized for 2 bedrooms with a maximum occupancy of 4 persons(2 per bedroom),for a total estimated flow of 400
gpd•
Filter:Zabel A-1801
r
i
i
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 2 of 3
EH Database v 1.0.1 AP1110446 EID1478067
7
,M PERMIT #: 13-SC-1478057
STATE OF FLORIDA APPLICATION #:AP1110445
DEPARTMENT OF HEALTH DATE PAID:
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FEE PAID:
CONSTRUCTION PERMIT RECEIPT #:
DOCUMENT #:PR908850
CONSTRUCTION PERMIT FOR: OSTDS Repair
APPLICANT: Alejandro Rebelo
PROPERTY ADDRESS: 353 NE 94 St Miami, FL 33138
LOT: 12 BLOCK: 45 SUBDIVISION:
PROPERTY ID #: 11-3206-013-6110 [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
t
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 [ 1,050 1 GALLONS / GPD New Septic Tank 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 I 7
D [ 150 1 SQUARE FEET Trench confiquration drain SYSTEM
R [ ] SQUARE FEET SYSTEM
A TYPE SYSTEM: [x) STANDARD [ ] FILLED [ ] MOUND [ ]
I CONFIGURATION: [x] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: F.F.E., 13.10'NGVD
I ELEVATION OF PROPOSED SYSTEM SITE [ 33.60 ] [ INCHES FT ] [ ABOVE BELOW BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 71.601 [ INCHES FT ] [ABOVE HELOW BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [ 0.001 INCHES EXCAVATION REQUIRED: [ 38.001 INCHES
System#1 designed to treat the whole flow.
O Inspector to verify the existing septic tank is properly abandoned before final approval.
T *Invert elevation of drainfield to be no less than 7.63' NGVD.
*Bottom of drainfield elevation to be no less than 7.13'NGVD.
H 'THIS PERMIT IS NOT FOR"ADDITION(s)".
E The system is sized for 2 bedrooms with a maximum occupancy of 4 persons(2 per bedroom),for a total estimated flow
of 400 gpd.
R
SPECIFICATIONS BY: William Woo rd TITLE:
APPROVED BY: TITLE: Dade CHD
Carlos za
DATE ISSUEDThe is r?i'•Ui'e�tJ Cri',^,rm a EXPIRATION DATE:
ilir r t _ a';all�on at the 09/09/2013
DH 4016, r'i(O�Ssoieteg a13 p�evi pps.ec�kibllaD rich may not be used) s
+ Incorporatedif�ec64E 610Q3,,„FSG Sq!?tnrjj,,q a"Ca`o )U tfe the Page 1 Of 3
n
x'i4l sub)El'�.i�$d• AP1110445 SE900851
a.
fetall;6i:':ion tnr. u,',I,rg a3$i,:i`> t;3}the 4�+�,t_i:�u'toC is n(ii'.
at the 10uC ISF at t?Ts,x raC?yE.0 tifife.
DOCUMENT #: PR908850
i
The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with s.
64E-6.013(3)(0, FAC.
4
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 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.