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PL-10-1819Scheduled Inspection Date: November 19, 2010 Inspector: Hernandez, Rafael Owner: HOLDER, QUINTON Job Address: 10643 NE 11 Avenue Miami Shores, FL Project: <NONE> Contractor: STATEWIDE SEPTIC CONNECTIONS Building Department Comments Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 I 0 Phone Number Inspection Number: INSP- 153310 Permit Number: PL10 -10 -1819 Permit Type: Paint Inspection Type: Final Work Classification: Addition /Alteration Parcel Number 1122320280340 Phone: (954)963 -0082 REAPLCE DRAINFIELD AND INSTALL DOSING TANK WITH PUMP Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments HRS APPROVAL IN FILE November 18, 2010 For Inspections please call: (305)762 - 4949 Page 7of7 Scheduled Inspection Date: November 17, 2010 Inspector: Hernandez, Rafael Owner: HOLDER, QUINTON Job Address: 10643 NE 11 Avenue Miami Shores, FL Project: <NONE> Contractor: STATEWIDE SEPTIC CONNECTIONS Building Department Comments November 16, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Inspection Number: INSP- 153310 Permit Number: PL10 -10 -1819 For Inspections please call: (305)762 -4949 Permit Type: Paint Inspection Type: Final Work Classification: Addition /Alteration Phone Number Parcel Number 1122320280340 Phone: (954)963 -0082 REAPLCE DRAINFIELD AND INSTALL DOSING TANK WITH PUMP Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments Page 10 of 14 Inspector it Comments: Signature t`, „ DIVISION OF Environmental Health Florida Department of Health Miami-Dade County Health Departme OSTDS/Well Division 11805 SW 26 St: • Miami, FL 33175 AL. SYSTEM PPROVAL PERMIT O v DATE PAID FEE :PAID: . . RECEIPT #: APPLICANT: AGENT: LOT' [ l [ 1 STATE OF FLORIDA DEPARTMENT OF HEAL '-I ONSITE SEWAGE T EATMENT AND DISPO CONSTRUCTION INSPECTION AND FINAL PROPERTY ADDRESS: 11E' : Y ' ✓ / r' _- BLOCK: '"O SUBDIVISION CHECKED [X] ITEMS ARE NOT EN . COMPLIANCE WITH . STATU ID ELD INST y . TION,� AREAg1 s X 3( 15[2] -22 S SOFT NU BER OF DRAINLINES t Tr DR INLINE SEPARATION 3g DR • INLINE SLOPE DE TH OF COVER f- ' 'I EL.' ATION [ABO - *BM SY TEM LOCATION NES [ TANK INSTALLATION [ TANK SIZE [1] , , : 0 [2]-70c-3/ �, s L ] [02] TANK MATERIAL( ;,:7� j am/ , [ ] [03] OUTLET DEVICE [ ] [ 1 [04] MULTI - CHAT! - A 1j]Ils [ ] [ 1 [05] OUTLET F gal. [ 1 [ 1 _ [06] LEGEND . , VY I eT ...� C 3 v , /;[ 1 ' [ ] [07] WATERTI H .111111111111. [ [08] LEVEL gm [09] DEPTH Td DRAINFIELD [11] DIS [ [t [ [15] [16] [ [18] DO [19] AGGREGATE SIZE [20] AGGRE [21] EGATE DEPTH /S/ FINAL SYS[APPROV ISAPPROVED]:. DH 4016 (Page 2), 10/97 (Previous, Editions May Be Used) Stock Number 5744002- 4016 -4 ] OR RULE AND MUST BE CORRECTED. SETBACKS [27] SURFACE WATER [28] ,DITCHES [29] PRIVATE WELLS [30] PUBLIC WELLS [31] IRRIGATION WELLS [32] POTABLE WATER LINES [33] BUILDING FOUNDATION 134] PROPERTY LINES, [3)] OTHER CONSTRUCTI [APPROV.ED DISAPPROVED]: PROPERTY ID #"/ ,/ -,. C FILLED / MOUND SYSTEM [36] DRAINFILLD COVER [37] SHOULDERS [38] SLOPES [39] 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 [48] OTHER. FILL +/EXCAVATION :' ERIAL [22] FILL AMOUNT J - [23] FILL TEXTURE [24] EXCAVATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL EXPLANATION OF VIOLATIONS / REMARKS: [ ABANDONMENT [49] TANK PUMPED - 1 [50] TANK CRUSHED & FILLED _/ C CHD DATE•)a 2 ') r � CHD DATEJC" " /c) PT 1: Applicant PT 2: Installer /Contractor PT 3: Building Department PT 4: Health Department - d FT Fr FT FT FT FT, 7 FT FT Fr t� Paget of 3 BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) (n -i-o n Iry Phone # ,51 4L+I+- 222 Owner's Address 1° (q NE it City M S h° re State L Zip 33 l 3 8 Tenant/Lessee Name Email Job Address (where the work is being done) Miami Shores Village Building Department 10050 N.E.2and Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 \oG3 NE it A er c City Miami Shores Village County Miami -Dade Zip 33( 3 8 Contractor's Address Submittal Fee $ , 5cio S_ �,_ ZG State FL— Value of Work For this Permit $ 2' Type of Work: ❑Addition ❑Alteration Describe Work: FOLIO /PARCEL# t — Z..2 z p 3 Is Building Historically Designated YES NO t E -mail Permit No. L.- Q — A S Master Permit No. Phone # Architect/Engineer's Name (if applicable) Phone # Flood Zone Contractor's Company Name S"f�4,lOa Vim, Sric Cr6" l hone # 3 f GI G. 3 - 5 City ,AiY.rn c!' Qualifier Name eVeXCEAS TA a*yl,®r". Phone # State Certificate or Registration No. 'S M ® C I 1 1 2-4 2.- Certificate of Competency No. Contact Phone Zip 53313 Square / Linear Footage Of Work: 2-2- S ❑New [A Repair/Replace ❑ Demolition R lace- f ` o h4 e(d �- I � ��-� t► s 1;1 'mil c.11-(4 Pk.nr. ******** ** * * * * * * * * * * * * * * ** * * ** * * * * * * * ** F ** ** * * * * * * ** * * * * * ** * * * * * * * * * * ** Permit Fee $ 3 ex, — CCF $ CO /CC $ Notary $ Training/Educa' on Fee $ Technology Fee $ Scanning $ Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ Total Fee Now Due $ See Reverse side -> 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 ELECTRICAL WORK, PLUMBING, SIGNS, WELLS, POOLS, FURNACES, BOILERS, HEATERS, TANKS and MR 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 COM ENCEMENT 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 $2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job site for the first inspection which occurs seven (7) days after the building permit is issued. In the absence of such posted notice, the inspection wil of bee'pprove and a reinspection fee will be charged. (k"Signatur Owner or Agent The foregoing instrument was acknowledged before me this t day of ©L-1" , 20 l0 by v- kotrik s j who is personally known to me or who has produced A'nv t-`te`E'c' As identification and who did take an oath. NOTARY PUBLIC: Sign: Print: APPROVED BY My Commission Expires: (Revised 07 /10 /07)(Revised 06/10/2009) `TERESA S MMO 348 \ \ \ \ \17/l� Comm* SOLO a��� Expires 11/812011 itr7 Plans Examiner Engineer Signature Contractor The foregoing instrument was acknowledged before me this IS day of l LJ Sign: Print: , 20 t v brc ari- rL -9-A -- -1- �.., t who is persotEly known to a or w nhas produced as identification and who did take an oath. NOTARY PUBLIC: 111111 AA /' 1 , 9 TH rr,:o �tC :• ' a My Commission Expires: ` s\ m j y %s 4 . ........• ' • • Zoning Clerk checked THIS CB NI ISSLlZD AS A � IIAtE CERTIFICATE HIS CER D .IIIJTAFF 8E TIES D CERTIFICATE T AF poF ATIVEI.Y ARMED, EX ITEVD OR ALTER TH E TS -. HER BY M 9®NTATIVE PRODUCER, INSURANCE tCE DOES NOT CONSTITUTE A [SURER tS AND THE C CAm HOLDEN CONTRACT flu wsLr�R AUTHORIZED T mews 0 • � r : srt��rme n rroral� , �r , �aprar_ --.. ate'— _ 1�1, . En IRA T: Waleoe I gel AD Droll deaf Ir tf$u PRO cmiffsdim folder [n g of such a�nd,� a). � q�e 0h Shp A �temaut an Betio Maize a T i confer �hls the I SSW 21st Street Hotlywap4. FL 33023 Phone (9509139-0324 IN SURED -- • — . hb 10/11/2010 12:59 9549895998 CERTIFICATE OF mpT't't OF frVpaR11M11 LIABILITY .� cl�dimww r1 10/11/10 fRMAT1 1.1� OR 7'IOnr d1uLY AND C � HOLDER. TMs Btatewld® SeptIo ConnectIons, In :1590 E. a Rd 07 pig Miramar, FL 3 I S4) • TYPE OP INSURANCE GOMA. ummua1Y © C !AMU I I I Mail Aariaffiena MT OFILIEB PEIt AUTOMO@2g WINERY -- I ❑ AAUTo I M' 0 ALL OWNED AIMS I r EecHEDULEDAUTOS I.! NIREp AUTOS ❑ — pase _10_," I Q azDUcraILE � Er YI _litr L.- N rA CR oe 'wr tibet^ M T'IFICATE HOLDCR WORD ES (1RQ91 IS) CIF E0 /E0 30t/d MIAMI SHORES laoso NE 2ND AVE MIAMI a KORESM FL :'x9135 MAIZE AND TYSON I J__ LL PAGE 87/87 aq — N° B r ot r WESTERN JOKED 1NSURANce ' C ae^ I 1 ' 4144 s TO $ i C.L:iiTlr:Y'TNfA9IHE P��}ES GF I1SIl7N (YtJRI{BER: —� 144 I TI;D. EN T ATAillir , .> R@SL $C sE ew [ aavE t v Igs�tED ram p C8R11FI Ib1AY � I��p p8 Iy�Y �7'/tIN, THB kI 8LJI4P WC � flF Art15� ; °14°THER li O FOR POLICY PERIOD uausmr>swu rt y D CON�1T1 N3 o SSUM BPOLICES. L U tS SWOW M DWI RIMMED BY BAD 81 IV st,� Tb j 7 $ � 1 '� UrJ � . __Ligy'YNU D ER GUT 0247 1, 1,.._._ WITS _17 1 MO EEO $ 50000 . 1 RA= .:1_00,000 90W/2011 MED �' U P me, & ADY INJURY r AL A y •SI UOTS • OOMPlQP MG $ � - t a siNoLE LIMB' - DJLY INJURY [Igrr swum GAILY MAT tPe - c PRopEmy DAMADR AOGREGA're C : EL EACH ACCIDENT J $ ^ — uL WEAVE • EA titer errs $ EL WAGE - Pow? - -•�• daSCRIPTIdN OPERATIONS I LOOATIONO EXTRA SPACE STORAGE IS AN ADD ITIONS INSLIRg tot, Aa l Ranarxssaeedurq, ie e � SHOULD ANY OF THE ABOVE DEECEISEDPIALZIES Ea OAI4CELLED BEFonn 17tE EXPIRA170N DA rN THESIBoir, NOT= WILL BE D EI yENED IN AociONDANOE TOWN THE PMI:0Y Meg/4 M AvrNOR¢ap R It4TAY11H ," ---` I 131111 M ORD coRPORATIbis. Ail rights raSSrved. Thar ACCORD name and WOO are registered marlls of AcORD 6ZL90ZZ90E LE :ZO OIOZ /bT /0Z CONSTRCICTION PERMIT FOR: APPLICANT: Quinton Holder PROPERTY ADDRESS: 10643 NE 11 Ave LOT: 6 PROPERTY ID Si 11- 2232-028 -0340 SYSTEM DESIGN AND SPECIFXCATZONS T [ A [ N [ • [ SPEiCIF'ICATIONS EY: APPROVED BY: 60/10 39dd sum: OF FLORIDA DEPARTMENT or /MALTS ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM BLOCK: 3 A0 N OSPINA Oopitw DATE ISSUED: ' 0/14/20 OSTDS Repair . .1 A 3os 1s6P9 -1 2 Miami, FL 33138 SUBDIVISION [SECTION, TOWNSHIP, RANG*, PARCEL NUMBER) [OR TAX YD DER] SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTX00 381.0065, F.S:, AND CHAPTER 64E --8, F.A.C. DEPARTMENT APPROVAL OY' SYSTSM DOES NOT GUARANTY, SATISFACTORY PERFORID(ANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY CHANGE IN MATERIAL FACTS, waSCH SERVED AS A BAS'S 1E'OR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO wpm THE PENMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT Xr•7 THIS PERMIT BEING MADE NULL AND 'VOID, ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WYTN OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. 750 ] GALL0N / GPD Septic CAPACITY 0 ] GALLONS / C,PD _ CAPACITY 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK :1230 GALLONS1 225 ] GALLONS DOSING TANK CAPACITY [37,50 ]GALLONS II[ 8 ]DOSES PER 24 HRS #Pumps [ 1 ] b [ 225 ] SQUARE FEET SYSTEM R [ 0 ] SQUARE PET SYSTEM A TYPE SYSTEM: I ;M] STANDARD [ ] FILLED I ] MOUND [ ] I CONFIGURATION: Cx] TRENCH [ 1 BED I J F LOCATION OF BENCHMARK: F.F.E.: 6,8' NGVD Y ELEVATION OF PROPOSED SYSTEM SITE [ 20.40 ] [[ NCktEs PT ] [ ABOVJr 4 EELow ID a'1�TCC C/ REFERENCE POINT E BOTTOM OF DRAINFIELU TO EF, [ 39,42](IINCHES FT ][ABOVE/1BELONbBENCHMARK /REFERENCE POINT D FILL REQUIRED; I. 0,00 ] INCHES EXCAVATION REQUIRED: [ 19.203 XacaaS 1— Existing 750 gal. septic tank certified by " Statewide Septic Connections Inc." on 10/11/2010 to remain. 2 - Install 225 sf O of drainfield In trench configuration. 3- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed T absorption bed. 4- Invert elevation of drainfield to be no less than 4.00' NG , of drainfield elevation to be no Tess H than 3.50' NGVD, 6. Install a 225 lift/dosing tank and all the requirements f -_ ' - t inla fl. , X THIS PERMIT IS NOT FOR AODITION(s), � mum 1041y7,8 DH 4016, 08/09 (Ob6iolutes all previous editions which easy not be used) Xnoorporat ©d: 64E - 6.003, FAC EXPIRATION DATE: a.cai ") $ PE7[tMIT 6: 13- SC. APPLICATION #: Ap981471 DATE PAID: FEE PAID: RECEIPT 5s DOCUMENT 8: PR824291 Dade Cab 01/12/2011 Paaa 1 of 3 6ZL90ZZ50E LE :Z(3 0T0Z /t7T /0T a Kutuu. Cacn DIOC re I resents 1 u teet and 1 inch = 40 feet. I 111 —Lll NO4 , AIPINErt" MIL ! F •r Fr —g .- Pcokic_min mi p m MU gli impa 6M il.MAN ma - mu Ms ;aim a 17.131$ • imam MIll MIll III k,_ OIMM gig a , cial rgrelmil 1111Erail me , Pi oNELTae ri i 1 • 11111111112• ammut ii.. Eki 'Er+ lig 1 y i+S ..----, 1 • • 1 gmasti • ........„ 1 11 ' , 1 1 didierim • ' ,... n ip. ii EA gm an imaq Nag il 1•1226m-aai lmil m 'I . „,.. MWMAMMiosiMi 1pg" & I r 3 Mil gillli Li :,., • •WO i 1 ii molim, il II _ - id MM ME M 11 j j 1 • • 1 1 11 Notes: Arl ir Site Plan submitted by PIgn Approved By 441 • DEPARTMENT OF HEALTH a.C&) APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERK I-- _— Permit Application Nuirez. 4- 14E. fl A ‘12,_i?i6c.e ' j Ou - ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT D-1 4015, 10/96 (Replaces HRS-H Form 4016 which may be used) (Stock Number 57414.002-4015-6) E13 0 39Vd STATE OF FLORIDA PART II - SITEPLAN i 4 ' w gnature " arektn • _ i ts(d '1/4. - 22S 4 " c.Vt 0 Z\;-% tmoti- -66- cb"-kroc4- kcb -rblliq /11? Title Date County Health Department Page 2 of 4 EZL92M5lae • LE :g OTOZ/t7T/In STATE OF FLORIDA DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #• CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: Quinton Holder PROPERTY ADDRESS: 10643 NE 11 Ave Miami, FL 33138 LOT: 6 PROPERTY ID #: 11- 2232 - 028 -0340 303 � P9 BLOCK: 3 SUBDIVISION: SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS 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 , RANGE 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 EING 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 [ 750 ] GALLONS / GPD Septic CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ 225 ] GALLONS DOSING TANK CAPACITY [37.50 IGALLONS @[ 6 ]DOSES PER 24 HRS #Pumps [ 1 1 D R A I N F I E L D 0 T H E R [ 225 ] SQUARE FEET SYSTEM [ 0 ] SQUARE FEET SYSTEM TYPE SYSTEM: [X] STANDARD [ ] FILLED [ ] MOUND [ ) CONFIGURATION: [X] TRENCH [ ] BED [ ] LOCATION OF BENCHMARK: F.F.E.: 6.8' NGVD ELEVATION OF PROPOSED SYSTEM SITE BOTTOM OF DRAINFIELD TO BE FILL REQUIRED: [ 0.00] INCHES EXCAVATION REQUIRED: ( 19.20 ] INCHES 1— Existing 750 gal. septic tank certified by " Statewide Septic Connections Inc." on 10/11/2010 to - emain. 2- Install 225 sf of drainfield in trench configuration. 3- Perimeter of excavation area shall be at least 2 ft wider and 'onger than the proposed absorption bed. 4- Invert elevation of drainfield to be no less than 4.00' NGV tt of drainfeld elevation to be no Tess than 3.50' NGVD. 6. Install a 225 Lift/dosing tank and all the requirements 1 ' m tt in n. THIS PERMIT IS NOT FOR ADDITION(s) SPECIFICATIONS BY: APPROVED BY: DATE ISSUED: DRO N OSPINA [ 10/14/2010 o N Ospina [SECTION, TOWNSHIP, [OR TAX ID NUMBER] DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E- 6.003, FAC APPLICATION #:AP981471 DOCUMENT #: PR824291 PERMIT #: 13-SC-1283042 RANGE, PARCEL NUMBER] ( 20.40 ] (I INCHES f FT ] [ ABOVE /� BELOW BENCHMARK /REFERENCE POINT [ 39.42 ] () INCHES f FT ] [ ABOVE d BELOW k BENCHMARK /REFERENCE POINT mtAilioAce l+ftni Dade CHD EXPIRATION DATE: 01112/2011 Page 1 of 3 Notes: to et eotm Site Plan submitted by: Plan Approved B y -- �^�,,, ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DH 4015, 10/96 (Replaces HRS -H Form 4016 which may be used) (Stock Number 5744- 002 - 4015 -6) co•Arcc40. EPARTMENT STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PERM Permit Application Nurtber, ae PART II - SITEPLAN - - t Scale: Each block re • resents 10 f ° et and 1 inch = 40 feet. 11111•11111111 IIM•1111•111111 " rnl®Ji111U•Mr L!U!ESIIM °¢" ■® 11111 \111 'rMMKA ! ' i !!c ■ . i • ■I1®k1UII � U ■ttLT!!! •UUI1111 iii ii` ii■ 1111A• ® ®f ®I." ! 111 — ® ®li 1161.11,1 ►EMINNE1111 213 1 t 1 Title Date County Health Department Page 2 of 4