Loading...
PLC-18-2376 (2)'PT18-231 � Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Permit NO.: PLC-9-18-2376 UIS } Permit Type: Plumbing -Commercial Work classification: Addition/Alteration Permit Status: Approved Issue Date: 08/06/2019 1 Expiration: 02/03/2020 Location Address Parcel Number Project 180 NE 99 ST, Miami Shores, FL 1132060132230 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: NOTE: NEED PERMIT FOR NEW SERVICE. YOU MAY BE ABLE TO CALL IT 180 N. E. 99 ST. PUMPS. Total Sq Feet: 79.00 Fees Amount CCF $8.40 DBPR Fee $6.30 DCA Fee $4.20 Education Surcharge $2.80 Permit Fee $420.00 Scanning Fee $12.00 Technology Fee $11.20 Total: $464.90 Building Department Copy Payments Date Paid Amt Paid Total Fees $464.90 Credit Card 08/06/2019 $264.90 Credit Card 09/06/2018 $200.00 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. Authorized Signature: Owner / Applicant / Contractor / Agent U Date August 06, 2019 Page 2 of 2 ., Miami Shores Village BUILDING PERMIT APPLICATION 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 Sub Permit No. G 06 2018 !`, -14k `- _ _ f FBC 201 OBUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION [:]RENEWAL PLUMBING [:]MECHANICAL PUBLIC WORKS ❑ CHANGE OF CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: —tm N 6 I 9 -11, S-vcz City: Miami Shores �� County: Miami Dade Zip: 3-3(3A Folio/Parcel#: 11 — 3020 (0 — Q � 5 — �^19o(30 Is the Building Historically Designated: Yes NO X Occupancy Type: Load: Construction Type: Flood Zone: 00 BFE: FFE: OWNER: Name (Fee Simple Titleholder): K%aw� SVyrc s L9 t-e t' L-L-L Phone#: L5o'51 3teq - 000 15 Address: At 1) -=�k S�: stfteiC #--50 1 City: `' ka" 6&J\ State: Zip: Tenant/Lessee Name: bC. —rI xo W C.0 IS 9 to Cc", Phone#: Email: OC5e-' IBC CONTRACTOR: Company Name: -' Address: I,Q, ✓ '5 6 (�'�.V � ��- City: VA State Qualifier Name: LOt U' S !�(N1 but'iq,IC' State Certification or Registration #: ,%AA C.4 Phone#: �J 94o — (0q.5-9' Zip: '. 3181 Phone#: UW)�5aco- -SJ TO—+ Certificate of Competency #: DESIGNER: Architect/Engineer: SDsea Grva,r� Phone#: Address: I ©��-�w OStrey� City: �CA4t A State: �(�t Zip: Value of Work for this Permit: $ 1 Li� �1 1000 -n 00 Square/Linear Footage of Work: � � -( !a Type of Work: ❑ Addition ❑ Alteration El New ❑ Repair/Replace ❑ Demolition Description of Work: Cmwt -iD 2142(` ( t /gyp 1 Specify color of color thru tile: Submittal Fee $ Permit Fee $ Scanning Fee $ Technology Fee Structural Reviews $_ (Revised02/24/2014) Radon Fee $ Training/Education Fee $ CCF $ CO/CC $ DBPR $ Notary $ Double Fee $ _ Bond $ TOTAL FEE NOW DUE $ q ! o w Bonding Company's Name (if applicable) Bonding Company's Address City Si Mortgage Lender's Name ' applicable) Mortgage Lender' ddress City Zip 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 OWNER or AGENT I The foregoing instrument was acknowledged before a this day of 20 by ► % K G L; who is ersonally known me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Sign: rQ1 G Print: Q 1 1 Seal: :i�`•"Y ORITMIMOUN MY COMMISSION # GG 162406 EXPIRM: December 14, 2021 80MOThriNePublic thtdenniter *************** APPROVED BY (Revised02/24/2014) Signature CONTRACTOR The7egoing instruAn was acknowledged before pme this day of GG 20 ! O by who is personally known to me or who has produced identification and who did take an oath. NOTARY PUBLIC: ;o1nHv iq�'•• Seal: �• '•v Plans Examiner Structural Review cATHERtNE A. Notary public _ State of Florida Commission # GG 104296 My Comm. Expires May 14, 2021 Ncnu,.d through Na::orwl Notary Assn. as **************** Zoning Clerk Property Search Application - Miami -Dade County Page 1 of 1 OFFICE OF THE PROPERTY APPRAISER Summary Report Property Information Folio: 11-3206-013-2230 Property Address: 180 NE 99 ST Miami Shores, FL 33138-2341 Owner MIAMI SHORES CENTER LLC Mailing Address 210 71 STREET #309 MIAMI BEACH, FL 33141 PA Primary Zone 6400 COMMERCIAL - CENTRAL Primary Land Use 1211 MIXED USE - STORE/RESIDENTIAL : RETAIL OUTLET Beds / Baths / Half 0/0/0 Floors 1 _ Living Units 0 Actual Area Sq.Ft Living Area Sq.Ft _ Adjusted Area 2,494 Sq.Ft Lot Size 5,850 Sq.Ft Year Built 1954 Assessment Information Year 2018 2017 2016 Land Value $152,100 $152,100 $152,100 Building Value $133,082 $133,082 $129,050 XF Value $16,982 $17,162 $17,342 Market Value $302,164 $302,344 $298,492 Assessed Value $302,164 $302,344 $290,885 Benefits Information Benefit Type 1 20181 2017` 2016 Non -Homestead Cap Assessment Reduction I $7,607 Note: Not all benefits are applicable to all Taxable Values (i.e. County, School Board, City, Regional). IShort Legal Description MIAMI SHORES SEC 1 AMD PB 10-70 LOT 1 BLK 17 LOT SIZE 45.000 X 130 OR 20241-3676 0202 6 (4) Generated On : 9/6/ Taxable Value Information 2018.. 2017 2 __..._................ County Exemption Value $0 $0 Taxable Value $302,164 $302,344 $290 School Board Exemption Value $0 $0 Taxable Value $302,164 $302,344 $298. City Exemption Value $0 $0 Taxable Value $302,164 $302,344 $290. Regional Exemption Value $0 $0 Taxable Value $302,164, $302,344 $290. Sales Information Previous OR Book - Price Qualification Description Sale Page 02/01/2002 $1,244,000 20241-3676 Other disqualified 05/01/1985 $500,000 12511-0993 Deeds that include more than of parcel 07/01/1976 1 $530,000 00000-00000 Sales which are qualified 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 Appra and Miami -Dade County assumes no liability, see full disclaimer and User Agreement at hftp://www.miamidade.gov/info/disclaimer.asp Version: https://www.miamidade.gov/propertysearch/ 9/6/2018 Detail by Entity Name Page I of 2 Florida Department of State t .or , '.,i �.... Department of State / Division of Corporations / Search Records / Detail By Docume-t Nu-ber / Detail by Entity Name Florida Limited Liability Company MIAMI SHORES CENTER, LLC Filina 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 Agent 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. DivitsioN of. Co'iPofaA'.or4s http://search. sunbiz. org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entity... 9/6/2018 Detail by Entity Name Page 2 of 2 210 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 04118/2018 -- ANNUAL REPORT tZl3 t.'20 t..-:.-....G. r{m@rl{irrFe..,n# 02/2312017 -- ANNUAL REPORT 0511212016 -- I.C, Arnendment 02/1012016 ANNUAL REPORT 03104/2015 -- ANNUAL RF.PORT 04/122013 -- ANNUAL REP09T 01/31/2012 --ANNUAL REPORT 010412011 —ANNUAL REPORT 02/1612010 -- ANNUAL REPORT' Q4'0.'.,.:t?t3()g.....:_r.NNUnt::_Ft .E.Q. T 02r0612008 -- ANNUAL REPORT 01/2912007 -- ANNUAL. REPORT 03/212006 -- ANNUAL REPORT 0212112005 -- ANNUAL REPORI ¢3129/ZQQ4._ ._tNNUAL.RUuRT 04/24/2003 -- ANNUAL REPORT 07,130/2002 -- ANNUAL. REPORT View image in PDF Format View image in PDF format View image in PDF format View image in PDF format View irnage in PDF format View image in PDF format View image in PDF format View image in PDF formal View image in PDF format F77T;T;e in PDF format View image in PDF romrat View image in PDF format View image in PDF format View image w PDF format View irnage in PDF format View image in PDF format View image. in PDF format View image in PDF format View image in PDF format View irnage in PDF format F1.>,Mle. of';Mr. Dime. e, ...a.. rn.i. : http://search. sunbiz. org/Inquiry/CorporationSearchISearchResultDetail?inquirytype=Entity... 9/6/2018 e-Permitting Search:- '� L MIAMI DADS Status of Plans Process: M2018019279 Application Date: 09/20/2018 Storage Location: By: Date Picked up: Review Reviewed By Est Comp Data Disp Date 11 Disposition DERM AGRAS MARICHAL, FRANK 09/20/2018 03/04/2019 A WASA CLEARE, LATARSHA 09/20/2018 01/18/2019 A PAYU FEE COL 09/21/2018 09/21/2018 A HRS GERARD PHILIZAIRE 01/28/2019 1 04/08/2019j A Disposition Legend: A=Approved, D=Disapproved, N=N/A, P=Approved as Noted Note: PAYU relates to payment of up -front fees only. Page: ..•• ...... . . ...... .. . ...... REVIEW STATUS INQUIRY SUCCESSFUL (NO MORE ENTRIES) • • • ! • • • •••••• BLDG Home Pag I BLDG Main Menu I BLDG Permit Menu I BLDG Plar> Processing Menu I Inspection Tvu I•Add ess ForniAL • • • • • • . • • •••••• • • ••••• Home I About I Phone Direetory I Pnv�cv I Disd: r-ner • • • • • • • • •• •• • •••••• E-mail your comments, questions and suggestions to Webmaster This page was last edited on: February 23, 2004 Web Site ® 2004 Miami -Dade County. All rights reserved. • • • • • •••••• 2019-ALLOCATION-00767 cvtit�T�Y , 3/4/2019 Issued Date: 3/4/2019 MIAMI SHORES CENTER LLC 210 71 STREET #309 MIAMI BEACH„ FL 33141 Sewer Connection at 180 NE 99 St 180 NE 99 St Miami Shores, FL 33138 RE: Sanitary Sewer Certification of Adequate Capacity The Miami -Dade County Department of Regulatory and Economic Resources (RER) has received your application for approval of additional sewer flows for the following project which is more specifically described in the attached project summary. Project Name: Sewer Connection at 180 NE 99 St / M2018019279 Project Location: 180 NE 99 ST, MIAMI SHORES, FL 331382341 Previous Use: Building in Septic System. Proposed Use: 2,494 SF Medical Office. Previous Flow: 0 GPD Total Calculated Flow: 499 GPD Allocated Flow (additional sewer flows): 499 GPD • • • • Sewer Utility: PRIVATE • • Receiving Pump Station: 99 - 1353A • • �: RER has evaluated your request in accordance with the terms and conditions set forth in Appendix A of th%:Mnsent;'Wee'(CAS�... No. 1:12-CV-24400-FAM) between the United States of America and Miami -Dade County. RER herebly'c%"flbs that ad(quate ; .... treatment and transmission capacity is available for the above described project, pursuant to the criterion st4 mlated in Appendix A of • said Consent Decree. .... .... ...•. ...... . . ..... Furthermore, be advised that this approval does not constitute departmental approval for the proposed pj6jVg?and is$L6jbtfto the ...... terms and conditions set forth in the Consent Decree. Additional reviews and approvals may be requirlq jrprr•other sectipns having • • jurisdiction over specific aspects of this project. Also, be advised that the gallons per day (GPD) flow deterntinaition indicated herein • are for sewer allocation purposes only (in compliance with the Consent Decree requirements) and may not be repre,""of GF?C •"' flows used in calculating connection fees by the utility providing the service. .'. ;. • •.; Be advised that this Sanitary Sewer Certification of Adequate Capacity (this letter) will expire within 90 days of the issue6te if the applicant does not obtain a building process number from the corresponding building official. However, if the building process number has already been obtained, this letter will expire within 180 days of the expiration date of the process number. Finally, if a Building Permit was secured for this project, this letter will expire within 150 days of the expiration date of the Building Permit. Should you have any questions regarding this matter, please contact the Miami -Dade Permitting and Inspecting Center (MDPIC) (786) 315-2800 or RER Office of Plan Review Services, Downtown Office (305) 372-6789. Sincerely, Lee N. Hefty Director of Environmental Resources Management For/By: Cristian Guerrero, P.E., Chief of Environmental Plan Review. Department of Regulatory and Economic Resources. Page 1 of 2 •• • • Sanitary Sewer Certification of Adequate Capacity Project Summary: Owner's Name: MIAMI SHORES CENTER LLC Owner's Address: 210 71 STREET #309 MIAMI BEACH„ FL 33141 EEOS Allocation Number: 2019-ALLOCATION-00767 Project: Sewer Connection at 180 NE 99 St / M2018019279 Proposed Use: 2,494 SF Medical Office. Pump Station: 99-1353A Projected NAPOT: 3.32 Proposed Projected NAPOT: 3.32 • • '� rit��.t • • � • • Y f Cr -t�SS. in"h`,�Sv�L� y r' �i ter y ', 'LaY1�: • ,-k� •� % ' • � . ;c.3 9'� • • • s��tif :=ci �`�5 r�'.`q� �S'� t •. r: y' r "R*' C 1, a.�l h.,� Yr � S\ t� R.n i `� L N "� '�Y c� inir �' �`...j'r y✓ ry"�� _ �, • !..'. ,'1:f: Li .: F !:[t=' �.;� 499 APP a crr 3/4/2019 ,.F�'�; 11320601379p f • • • 180 NE 99 St pose • �LC1823i6. • • • • SWf2 w••• • otal: •••••• •••••• 499 GPD Page 2 of 2 MIMI®DIADE • miamidade.Vv Water and Sewer PO Box 330316 Miami, Florida 33233-0316 T 786-268-5360 F 786-268-5150 VERIFICATION FORM DATE: January 18, 2019 BLDG PROCESS #: M2018019279 VF# 18-21790-VF - 13 INVOICE(S)#: N 00058780 THIS FORM IS NOT VALID WITHOUT A PAID INVOICE AND EXPIRES ONE YEAR FROM THE DAT E ON FURM PROJECT NAME: MIAMI SHORES CENTER LLC PROJECT/AGREEMENT NUMBER: 21790 PROJECT DESCRIPTION: FIRST TIME SEWER CONNECTION MEDICAL OFFICE Folio 'Address Zip Code Lot ;;:"''!'Block; ' 'Prsed "sq. ft. ... 1132060132230 180 NE 99 ST 33138 1 LOT 1 1 BLK 17 1 2,494 2,494 AffordableConnection Type Reason for'Conh'6�tion Information Critical Habitat Wetlan&!�.'' Inspection Water, Sewer I First Time Connection No No I No 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. 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: 1 2-CV-24400-FAM) OR DOH ONSITE SEWER TREATMENT & DISPOSAL SYSTEM RULES & STATUES. Prepare by: Latarsha Cleare Approved by: Luis Delgado Printed Name of Reviewer Printed Name of Supervisor Page 1 of 1 Vi STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM PERMIT # :13-SC-1936639 APPLICATION # : AP 1405856 DATE PAID: FEE PAID: RECEIPT #: DOCUMENT # : PR1210203 CONSTRUCTION PERMIT FOR: OSTDS Abandonment w APPLICANT: (Miami Shores Center LLC) PROPERTY ADDRESS: 180 NE 99 St Miami, FL 33138 LOT: 1 BLOCK: 17 SUBDIVISION - PROPERTY ID #: 11-3206-013-2230 (SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] (OR TAX ID NUMBER] 0 SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND MSTANDARDS ,"e••SECTIj)pre••• 361.0065, F.S., AND CHAPTER 64E-6, F.A.C. DEPARTMENT APPROVAL OF SYSTDU DhS NCO .;VARANTEE +• SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANG$••Lt'i MhAUAL: FACTS...:. WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE AW::a'UXT TO MQDIFY %ME • PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING•41� E NU= 'tosw VOIp!•e•. ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE,, WIN O!AgIL••rEDERAL,••� STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. •Goes• • • a•:•e• • SYSTEM DESIGN AND SPECIFICATIONS �•+••+ v • • • • • .•sue• T ( 1 GALLONS / GPD CAPACITY •sse•• A ( 1 GALLONS / GPD CAPACITY • • • •es.•• N ( I GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK-1250 GALLONS: •e•• • + K [ GALLONS DOSING TANK CAPACITY ( ]GALLONS @[ ]DOSES PER 24 HRS #Pumps D ( 1 SQUARE FEET R [ ] SQUARE FEET A TYPE SYSTEM: ( : STANDARD I CONFIGURATION: ( 1 TRENCH N F LOCATION OF BENCHMARK: I ELEVATION OF PROPOSED SYSTEM SITE E BOTTOM OF DRAINFIELD TO BE L D F 0 T H E R SYSTEM SYSTEM [ ] FILLED ( ] MOUND ( ] BED ( ] M ( ] [ ] [ ABOVE / BELOW ]BENCHMARK/REFERENCE POINT ][ ; ][ABOVE/ BE L01i I BENCHMARK/REFERENCE POINT ILL REQUIRE[): t U.UU j LINCHK, Kr-WUlttk.L: L j1[Vl.na3 Have the tank abandoned in accordance with the fo;;owing 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 tank shall be filled with clean sand or other suitable material. and completely covered with soil. Have the system inspected by the health department after it has been pumped and ruptured but before ;t is filled with sand and covered SPECIFICATIONS BY: TITLE: APPROVED BY: TITLE: Environmental Specialist II Eti Pnr¢ra Dade CHD DATE ISSUED: 04/'03/2019 EXPIRATION DATE: 07/02/2019 DR 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 AP1405656 Sa-1