PLC-18-2374 (2)Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Permit NO.: PLC-9-18-2374
�� IL War*
Type: Plumbing - Commercial
IF Classification: Addition/Alteration
Permit status: Approved
Issue Date: 08/06/2019 1 Expiration: 02/03/2020
Location Address Parcel Number Project
9806 NE 2 AVE, Miami Shores, FL 1132060132241 NE 2 AVE SEWER CONNECTION
Contacts
MIAMI SHORES CENTER LLC Owner MIAMI SHORES CENTER LLC Applicant
20171 ST 309, MIAMI BEACH, FL 33141 20171 ST 309, MIAMI BEACH, FL 33141
Mobile:7862368569 ORIT@ELYSEEINC.COM Mobile:7862368569 ORIT@ELYSEEINC.COM
Other:3058648885 Other:3058648885
IMBURGIA CONSTRUCTION SERVICES, Contractor
INC.
LOUIS IMBURGIA
12555 Biscayne Blvd #888, North Miami, FL 33181
Business:3059406957 NOELLE@IMBURGIAREALTY.COM
Mobile: 3055255707
Description: CONNECT TO SEWER LINES. Valuation: $ 14,000.00 Inspection Requests:
305-762-4949
TotalSq Feet: 75.00
Fees
Amount
CCF
$8.40
DBPR Fee
$6.30
DCA Fee
$4.20
Education Surcharge
$2.80
Permit Fee
$420.00
Scanning Fee
$9.00
Technology Fee
$11.20
Total:
$461.90
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$461.90
Credit Card
09/06/2018 $200.00
Credit Card
08/06/2019 $261.90
Amount Due:
$0.00
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 and zoning. Futhermore, I authorize the above named contractor to do the work stated.
I
Authorized Signature: Owner / Applicant / Contractor / Agent
Date
August 06, 2019 Page 2 of 2
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
BUILDING
PERMIT APPLICATION
BUILDING ❑ ELECTRIC ❑ ROOFING
❑PLUMBING [:]MECHANICAL [:]PUBLICWORKS
JOB ADDRESS: ` UO Ce k Oq rd
G 0 6 2018
cm
FBC 20 I�
Master Permit NoTk,0_ (9 - 23
Sub Permit No.
❑ REVISION ❑ EXTENSION ❑ RENEWAL
❑ CHANGE OF ❑ CANCELLATION ❑ SHOP
CONTRACTOR DRAWINGS
City: Miami Shores County: Miami Dade zip: :53 ►30
Folio/Parcel#: ((— 3 c20 (o — 013 - as 4 j Is the Building Historically Designated: Yes NO �1
Occupancy Type: Load: Construction Type: Flood Zone: N0 BFE: FFE:
OWNER: Name (Fee Simple Titleholder):__ «" SMMS QX A: e2 _ LLCI Phone#: (30:5) N A —OH 5
Address: (910 -:=)`i qATC2 * _#W 9
City: wtalfxc k ua_c� I,� State: IF � Zip: 5314 (
Tenant/Lessee Name: kAAA ( ► `�a�Q� �, � Phone#:
Email: 05'k�- A e-IVS .9,1kNC • C O(` _\
CONTRACTOR: Company Name: 1 `(J� I��y,vl1G dC,t Uhone#: CJ' 4� " �O9 J
Address: U ,55 &I5
City: NC)`'�V \ G/u1A4 State: Zip:
Qualifier Name: LAn)w S Sfu�c.�rG 1 a Phone#: _3Q5. C9625 _ 5J0_3
State Certification or Registration #:
Certificate of Competency #:
DESIGNER: Architect/ ggg r: q r� Phoned-4942) ` 9& — 1000
Address: � qOW S(A) l; C S'�Q_Lt City: `QiYl,1.t State: (PI —zip: 5 3 ((o
Value of Work for this Permit: $ 14 1 dco 'W Square/Linear Footage of Work: '3 5 jpde
Type of Work: ❑ Addition ❑ Alteration ❑ New ❑ Repair/Replace ❑ Demolition
Description of Work: C-UNr\24it -J0 S We.C' (I MA
i
Specify color of color thru tile: 4
Submittal Fee $ Permit Fee $ . CCF $ CO/CC $
Scanning Fee $
Technology Fee $,
Radon Fee $
Training/Education Fee $
DBPR $
Notary $.
Double Fee $
Structural Reviews $
(Revised02/24/2014)
Bond $
TOTAL FEE NOW DUE $ /•
Bonding Company's
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 or AGE11T CONTRACTOR
The foregoing instrument was a nowledged before a this
day of 20 I by
ho is (erso-nally known
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign:
Print:
Seal: �' A
APPROVED BY
The foregoing instrume t was acknowledged before me this
day of ` % (i �— 20 IS by
1s�tA,4- 0 Jam, who is personal known to
me or who has produced as
identification and who did take an oath.
NOTARY PUBLIC:
Sign: G
IPlans Examiner
Print:�-
,: otr�=� rv;�-•,
SeaI:Notary
CATHERINE
Public - of FloridaCommission
:A.DUFFIN
04296MyComm.
Expiry 14,2021
I)ondcdthrough NaotaryAssn,
Zoning
(Revised02/24/20141
Structural Review
Clerk
Property Search Application - Miami -Dade County Page 1 of 1
OF THE PROPERTY APPRAISER
OFFICE
Summary Report
Property Information
Folio:
11-3206-013-2241
Property Address:
9806 NE 2 AVE
Miami Shores, FL 33138-2313
Owner
MIAMI SHORES CENTER LLC
Mailing Address
21071 ST#309
MIAMI BEACH, FL 33141
PA Primary Zone
6400 COMMERCIAL - CENTRAL
Primary Land Use
1111 STORE: RETAIL OUTLET
Beds / Baths / Half
0/2/0
Floors
2
Living Units
0
Actual Area
Sq.Ft
Living Area
Sq.Ft
Adjusted Area
13,575 Sq.Ft
Lot Size
12,541 Sq.Ft
Year Built
1947
Assessment Information
Year
2018
2017
2016
Land Value
$326,066
$326,066
$326,066
Building Value
$626,298
$626,298
$596,473
XF Value
$11,337
$11,476
$11,614
Market Value
$963,701
$963,840
$934,153
Assessed Value
$963,701
$963,840
$906,929
Benefits Information
Benefit
Type
2018
2017
2016
Non -Homestead Cap
Assessment Reduction
$27,224
Note: Not all benefits are applicable to all Taxable Values (i.e. County,
School Board, City, Regional).
Short Legal Description
MIAMI SHORES SEC 1 AMD PB 10-70
W73FT OF LOTS 3 & 4 & LOT 5 LESS
S19.71 FT OF E49.67FT & LESS N
4.92FT OF E57FT BLK 17
LOT SIZE 12541 SQ FT
Generated On : 9/6/2018
Taxable Value Information
2018' 2017i 2016
County
Exemption Value
$0
$0
$0
Taxable Value
1 $963,701
$963,840
$906,929
School Board
Exemption Value
$0
$0
$0
Taxable Value
$963,701
$963,840
$934,153
City
Exemption Value
$0
$0
$0
Taxable Value
$963,701
$963,840
$906,929
Regional��
Exemption Value
$0
$0
$0
Taxable Value 1$963,701
$963,8401
$906,929
Sales Information
Previous
OR Book -
Price
Qualification Description
Sale
Page
02/01/2002
$1,244,000
20241-3676
Other disqualified
Deeds that include more than one
05/01/1985
$500,000
12511-0993
parcel
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 hfp://www.miamidade.gov/info/disclaimer.asp
Version:
https://www.miamidade.gov/propertysearch/ 9/6/2018
Detail by Entity Name
Page 1 of 2
Flnnda Department of State
Department of State / Division of Corporations / Search Records / Detail By Document Number /
Detail by Entity Name
Florida Limited Liability Company
MIAMI SHORES CENTER, LLC
Filinq Information
Document Number
L02000000072
FEI/EIN Number
02-0533246
Date Filed
12/26/2001
State
FL
Status
ACTIVE
Last Event
LC AMENDMENT
Event Date Filed
05/31/2017
Event Effective Date
NONE
Principal Address
210 - 71 ST STREET
SUITE 309
MIAMI BEACH, FL 33141
Changed: 04/03/2009
Mailing Address
210 - 71 ST STREET
SUITE 309
MIAMI BEACH, FL 33141
Changed: 04/03/2009
Registered Aqent Name & Address
PIOTRKOWSKI, JOEL SESQ
317 71 ST STREET
MIAMI BEACH, FL 33141
Name Changed: 01/04/2011
Address Changed: 01/04/2011
Authorized Person(s) Detail
Name & Address
Title Manager
Mussaffi Investments, Inc.
Di•i':"SION i:4' "ORPORAT nNs
http://search. sunbiz.org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entity... 9/6/2018
Detail by Entity Name
• 210 71ST STREET, SUITE 309
MIAMI BEACH, FL 33141
Title Manager
Yehezkel, Haim
210 - 71 ST STREET
SUITE 309
MIAMI BEACH, FL 33141
Annual Reports
Report Year Filed Date
2016 02/10/2016
2017 02/23/2017
2018 04/18/2018
Document Images
04/18/2015 -- ANNUAL REPORT'
pC/31(1t3t.... c.�..C_f.nenli ze0f
0212312017 -- ANNUAL REPORT
0511212016 -- LC Amendment
02.110,'2016 -ANNUAL REPORT
03/04/2015 -- ANNUAL REPORT"
04i1212013 -- ANNUAL REPORT
QV31/2012--ANNUAL. REPORT
01/04,,2011 ANNUAL REPORT
02116/2010 -- ANNUAL REPORT'
94fQ3//Z29......-..t`:I�NUAt::_F?F F ART
021061200LT -- ANNUAL REPORT
01%2912007 -- ANNUAL. REPORT
03.121i2006 -ANNUAL REPORT
0212V2005 -- ANNUAL REPORT
03/2912004 -- ANNUAL REPORT
04/24/2003 -- ANNUAL. REPORT
0773012002 -- ANNUAL. REPORT
12.126/2001 . Flonda Limited Li- il,t4tj
View image in PDF format.
View image in PDF format
View image in PDF format
View image in PDF format
View image in PDF format
nJ,, a De, ,.^e::t of ..t ,.
Page 2 of 2
http://search. sunbiz. org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entity... 9/6/2018
MIAMFDADE
miamidade.gov
VERIFICATION FORM
Water and Sewer
PO Box 330316
Miami, Florida 33233-0316
T 786-268-5360 F 786-268-5150
DATE;
I December 11, 2018
BLDG PROCESS #:
M2018019277 / M2018019278
VF#
18-20180-VF - 141
INVOICE(S) #:
N00054837
THIS FORM IS NOT VALID WITHOUT A PAID INVOICE AND EXPIKES UNE PEAK FROM T HE uA i E ON FORM
PROJECT NAME: MIAMI SHORES CENTER LLC
PROJECT/AGREEMENT NUMBER: 20180
PROJECT DESCRIPTION: FIRST TIME SEWER CONNECTION WITH PRIVATE PUMP STATION
r- . .• . . . • . . . . .3.T . ..•
Water, Private PumpStation First Time Connection No I No I No I N/A
THIS VERIFICATION LETTER CERTIFIES THAT AVAILABILITY OF A WATER AND/OR SEWER MAIN ONLY, AND IT DOES NOT GUARANTEE THE
EXISTENCE OF A WATER SERVICE LINE, FIRE LINE OR OF A SEWER LATERAL WITH SUFFICIENT DEPTH TO SERVE THE PROPERTY. FOR
ADDITIONAL INFORMATION EMAIL NEWBUSINESSSUPVLIST@MiAMIDADE.GOV. SHOULD IT BECOME NECESSARY TO INSTALL A SERVICE LINE
AND/OR A SEWER LATERAL MDWASD REQUIRES THAT THE DEVELOPER RETAINS SERVICES FROM DESIGNERS AND CONTRACTORS WITH SKILL
SETS FOR DESIGNING, BUILDING, AND CONNECTING TO PUBLIC WATER AND SEWER SYSTEMS. A WATER AND/OR SEWER AGREEMENT MAY BE
REQUIRED. AN INSPECTION FOR ANY EXISTING SERVICES WILL BE PROCESSED WITH THIS FORM, AND A SERVICE UPGRADE MAY BE
REQUIRED WHICH MAY TAKE UP TO 12 WEEKS.
THIS IS TO CERTIFY THAT THE MIAMI-DADE WATER AND SEWER DEPARTMENT DOES HAVE A(N)12 INCH WATER MAIN AND/OR DOES NOT HAVE
A(N) INCH GRAVITY SEWER MAIN ABUTTING THE SUBJECT PROPERTY.
Office Building 5 d/100 sq ft
5245
262
262
Retail 10 d/100 sq ft
5245
525
525
Physician's Office (including Dentist, Chiropractor,
Optometrist, Acupuncturist, and Ophthalmologist. Rated
1000
a 200
200
as office: Psychiatrist, Psychologist, Speech therapist (20
d/100 sq ft
Office Building 5 d/100 sq ft
5245
262
262
Office Building 5 d/100 sq ft
830t
42
42
Theatre Indoor 1 d/seat
330
330
330
mm=Mr
2018 - Office Building 5 d/100 sq ft
5245
262
0
2018 - Retail 10 d/100 sq ft
5245
525
0
2018 - Physician's Office (including Dentist, Chiropractor,
Optometrist, Acupuncturist, and Ophthalmologist. Rated
1000
200
0
as office: Psychiatrist, Psychologist, Speech therapist (20
d/100 sq ft
2018 - Office Building 5 d/100 sq ft
5245
262
0
2018 - Office Building 5 d/100 sq ft
830
42
0
2018 - Theatre Indoor 1 d/seat
330
330
0
WE ARE WILLING TO SERVE THE SUBJECT PROPERTY, SUBJECT TO PROHIBITIONS, OR RESTRICTIONS OF GOVERNMENTAL AGENCIES HAVING
JURISDICTION OVER MATTERS OF THE ANTICIPATED DAILY WATER AND/OR SEWAGE FLOW FOR THIS PROJECT WHICH WILL BE THE NUMBER
OF GALLONS PER DAY INCREASE STATED ABOVE. IF "WILL HAVE", UPON PROPER CONVEYANCE AND PLACEMENT INTO SERVICE OF WATER
AND/OR SEWER FACILITIES BY THE DEVELOPER UNDER AGREEMENT IF APPLICABLE WITH THE DEPARTMENT. FURTHERMORE, APPROVAL OF
ALL SEWAGE FLOWS INTO THE DEPARTMENT'S SYSTEM MUST BE OBTAINED FROM D.E.R.M. SUBJECT TO RER'S TERMS AND CONDITIONS SET
FORTH IN THE CONSENT DECREE (CASE NO. 1:12-CV-24400-FAM) OR DOH ONSITE SEWER TREATMENT & DISPOSAL SYSTEM RULES & STATUES.
COMMENTS: Refunds are based on the date of payment and subject to State Statute 95-11. Some fees are not refundable. Only 5/8" meter for domestic
Page 1 of 3
MIAMM�IADE
Water and Sewer
PO Box 330316
Miami, Florida 33233-0316
miamidadc. v T 786-268-5360 F 786-268-5150
service and no irrigation meter: N/A
FIRST TIME SEWER CONNECTION FOR OFFICE, MEDICAL OFFICE, RETAIL & THEATER PER CITY OF MIAMI SHORES REPORT REPLACING OFFICE,
MEDICAL OFFICE, RETAIL & THEATER WATER ONLY SEE M2018012592 / N00053939 FOR 180 NE 99 S & M2018019279 180 NE 99 ST
CUSTOMER NAME: JOE CHAN CUSTOMER PHONE:
Prepare by: Latarsha Cleare
Printed Name of Reviewer
Attached the Comprehensive Plannin,
Approved by: Luis Delgado
Printed Name of Supervisor
i and Water SuDDIV Certification Letter
Page 2 of 3
MI�DiA
• DE
0,mumm mad.
vvater ano newer
PO Box 330316
Miami, Florida 33233-0316
T 786-268-5360 F 786-268-5150
Water Supply Certification Number: WSC-20180-VF -141
Water Supply Certification Issued Date: December 11, 2018
Building Process Number:M2018019277 / M2018019278
Agent/Representative: Owner:
JOE CHAN MIAMI SHORES CENTER LLC
210 - 71ST STREET SUITE 309
MIAMI BEACHFLORIDA 33141
Re: Adequate Water Supply Certification for the Project MIAMI SHORES CENTER LLC, Number 18-20180-VF -141
The Miami -Dade Water and Sewer Department (Department) has received your request to receive water services to serve the following
project which is more specifically described in the attached Agreement, Verification Form, or Ordinance Letter.
Project Location
r• .'
1132060132240
9830 NE 2 AVE
33138
MIAMI SHORES
BLK 17
16,735
16,735
SEC 1 AMD
1132060132241
9806 NE 2 AVE
33138
LOTS 3 & 4 &
LOT 5
BLK 17
13,575
13,575
Office Building 5 d/100 sq ft
5245
262
262
Retail 10 d/100 sq ft
5245
525
525
Physician's Office (including Dentist, Chiropractor,
Optometrist, Acupuncturist, and Ophthalmologist. Rated
1000
200
200
as office: Psychiatrist, Psychologist, Speech therapist (20
d/100 sq ft
Office Building 5 d/100 sq ft
5245
262
262
Office Building 5 d/100 sq ft
830
42
42
Theatre Indoor 1 d/seat
330
330
330
':,7 . r'a
. .. -
. i .
SM ! .
2018 - Office Building 5 d/100 sq ft
5245
262
0
2018 - Retail 10 d/100 s ft
5245
525
0
2018 - Physician's Office (including Dentist, Chiropractor,
I
Optometrist, Acupuncturist, and Ophthalmologist. Rated
1000
200
0
as office: Psychiatrist, Psychologist, Speech therapist (20
d/100 sq ft
2018 - Office Building 5 d/100 sq ft
5245
262
0
2018 - Office Building 5 d/100 sq ft
830
42
0
2018 - Theatre Indoor 1 d/seat
330
330
0
Totals
,,-
`Totat Water GPD Pro osed 1 se �r y.
;Total Water Credit GPD (�►Prsreviou low
a Reserved Flow (NetJWat6r) W` ,
The Department has evaluated your request pursuant to Policy CIE-5D and WS-2C in the County's Comprehensive Development Master
Plan and Limiting Condition No. 5. of the South Florida Water Management District Water Use Permit Number 13-00017-W. Based on its
review of all applicable information, the Department hereby certifies that adequate water supply is available to serve the above described
project.
This Adequate Water Supply Certification will expire if a building permit is not applied for within 365 days of the date of issuance of said
certification. If an Agreement is executed for the proposed project, the certification will remain active with the terms of the Agreement until
such time as the building permit is applied for. If a building permit is applied for in accordance with the aforementioned conditions, this
certification will remain active with the building permit process.
Furthermore, be advised that this adequate water supply certification does not constitute Department approval for the proposed project.
Additional reviews and approval may be required from sections having jurisdiction over specific aspects of this project.
Should you have any questions regarding this matter, please contact Maria A. Valdes, Chief, Planning and Water Certification Section, (786)
552-8198 or via email at mavald miamidade.gov.
Sincerely,
Latarsha Cleare
New Business Representative
Page 3 of 3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR: OSTDS Abandonment
APPLICANT: (Miami Shores Center LLC)
PROPERTY ADDRESS- 9830 NE 2 Ave Miami, FL 33138
PERMIT # :13-SC-1936548
APPLICATION #: AP1405861
DATE PAID:
FEE PAID:
RECEIPT #:
DOCUMENT #: PR1210198
LOT: NA BLOCK: 17 SUBDIVISION:
PROPERTY ID #: 11-3206-013-2240 [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 SYSTSM r00ES NO3••pUARANTA9•.••
SATISFACTORY PERFORMANCE FOR ANY SPECIFIC
PERIOD OF TIME. ANY CHANGE•• IN^ MATERIAiw• FACTS, ••
WHICH SERVED AS A BASIS FOR ISSUANCE OF
THIS PERMIT, REQUIRE THE APPTPXM;C TOI.NiODI�Y TBB••:•
PERMIT APPLICATION. SUCH MODIFICATIONS MAY
RESULT IN THIS PERMIT BEING.0GLO NULL AND VOIR.
ISSUANCE OF THIS PERMIT DOES NOT EXEMPT
THE APPLICANT FROM COMPLIANCE *,,7Ki'H OTH3A..FEDERA1,*•••.
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. •.•••� •a••••
••••+
ri '•••
SYSTEM DESIGN AND SPECIFICATIONS
•.a••• �•••••
�•••••
T [ J GALLONS / GPD
a
•
CAPACITY � '�•• • •
A ( j GALLONS / GPD
CAPACITY • • �..•i• ••.•••
N f j GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK.1250 GALLONS]• a4090•
K ( [ GALLONS DOSING TANK CAPACITY (
]GALLONS Q[ ]DOSES PER 24•HRS ii�Pus, a•[ "j •
•ali•
D ( ] SQUARE FEET
R [ J SQUARE FEET
A TYPE SYSTEM: [ J STANDARD
I CONFIGURATION: [ J TRENCH
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE
E BOTTOM OF DRAINFIELD TO BE
L
D 1
O
T
H
E
R
SYSTEM
SYSTEM
[ J FILLED [ J MOUND
[ ] BED ( ]
][ABOVE/ BELOW jBENCHMARK/REFERENCE POINT
][ABOVE/ BELOWJBENCHMARK/REFERENCE POINT
Lj Kr.WULKEU: ( U.UU ] INCHES EXCAVATION REQUIRED: ( 1 INCHES
ive the tank abandoned in accordance with the following procedures:(a) The tank shall be pumped out.(b) The bottom of
tank shall be opened or ruptured, or the entire tank collapsed so as to prevent the tank from retaining water, and(c) The
A shall be filled with clean sand or other suitable material, and completely covered with soil.Have the system inspected
the health department after it has been pumped and ruptured but before it is filled with sand and covered.
SPECIFICATIONS BY: TITLE:
APPROVED BY: TITLE: Environmental Specialist II
ErLck VPorora
DATE ISSUED: 04/03/2019 EXPIRATION DATE
DR 4016, 08/09 (Obsoletes all Previous editions which may not be used)
Incorporated: 64E-6.003, FAC
v 1.1.4 AP1405861 SE-1
Dade CHD
07/02/2019
Page 1 of 3