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PL-10-108Scheduled Inspection Date: February 26, 2010 Inspector: Hernandez, Rafael Owner: LEGO, JAMES REGIS Job Address: 163 NW 100 Street Project <NONE> Miami Shores, FL Contractor: JOE LEWIS SPECIALTY SEPTIC Building Department Comments February 25, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 Phone Number Inspection Number: INSP - 136413 Permit Number: PL -1 -10 -108 For Inspections please call: (305)762 -4949 C,L- Permft Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Parcel Number 1131010230310 Phone: (305)662 -7979 NEW SEPTIC SYSTEM TANK AND DRAINFIELD Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments v Page 7 of 11 'f Inspection Number: INSP - 134074 Scheduled Inspection Date: February 24, 2010 Inspector: Hernandez, Rafael Owner: LEGO, JAMES REGIS Job Address: 163 NW 100 Street Miami Shores, FL Project: <NONE> Contractor: JOE LEWIS SPECIALTY SEPTIC Building Department Comments February 23, 2010 Inspection Worksheet Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Permit Number: PL -1 -10 -108 Permit Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number Parcel Number 1131010230310 Phone: (305)662 -7979 NEW SEPTIC SYSTEM TANK AND DRAINFIELD Passed Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled until re- inspection fee is paid. Inspector Comments APt (55 Page 12 of 34 APPLICANT James Regis Lego Comments: CoNSTEtUCTIO2$ C FaNAt. SYSTEM [ CHECKED 21 to-i - is - y)7-z STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL 'APPROVAL AGENT: Joe Lowla Joe Lewis S • Well SEPTIC PROPERTY ADDRESS: 163 NW 100 St Miami FL 33150 LOT: 14 SUBDIVISION: [ 04 ] MULTI - CHAMBERED [05] OUTLET FILTER APPROVED APPROVED Bonmar Park • X ITEMS ARE NOT ]N COMPLIANCE WITH STATUTE OR RULE AND MUST HE C TANMC INSTALLATION [ 01] TANK SIZE [ 900.00 [2] [02] TANK MATERIAL Concrete [03] OUTLET DEVICE L-r N Zabel 1063 LEGEND 1, 13-076 -04DC3 [07] WATERTIGHT [09] LEVEL 1091 DEPTH TO LID DRAINFIELD INSTALLATION [10] AREA 11] 225 [2] SQFT [11] DISTRIBUTEON BOX HEADER X 1123 NUMBER OF DRAINLINES 1-. 4.00, 2. [13] DRAINLINE SEPARATION [14] DRAINLINE SLOPE [15] DEPTH OF COVER [16] ELEVATION [ ABOVE / 3bm 50.40 [17] SYSTEM LOCATION �® [1B] DOSING PUMPS [19] AGGREGATE SIZE [20] AGGREGATE EXCESSIVE FINES [21] AGGBIGATE DEPTH FILL / EXCAVATION MATERIAL [22] FILL AMOUNT [23] FILL TEXTURE [24] EXCAVATION DEPTH [25) AREA REPLACED [26] REPLACEMENT MATERIAL Comments are on page 2. 2. BELOW / DISAPPROVED ]: ana anquaastioa of vaoiatione on following page) DH 4016, 10/97 (Previous Editions May Be Used) EH Databa00 v 1.0.1 BLOCK: 4 ID #: 11- 3101- 023 -0310 AP9488G3 [36) [37] [38] [39] [4O] 1411 [ [43] [44] [ [46] [Q (483 FILLED / MOUND SYSTEM Ronald E Cove (Dada County Enviromn.nlal H.a1t1) E Cave (Dade County EnI:ro m anal Hal th) APPLICATION *: AP94886 3 PERMIT a : 13 -SC- 1116582 SETBACKS [2 SURFACE WATER [28] DITCHES (293 PRIVATE WELLS (303 Pt7BLIC WELLS [31] IRRIGATION WELLS (32] POTAELE WATER 1333 BUThDING FOUNDATIONS [34] PROPERTY LINES [35] OTHER DOCENT #1F1777385 DATE PAI;01/15/2010 r sEE EATD:20 0.00 REG$IPT # :13 - P I D- 1220239 DRAXNFIELD COVER SHOULDERS SLOPES STABILIZATION ADDITIONAL INFORMATION / DISAPPROVED l: Dade GTED. FT FT FT FT FT 80 FT 5 tank FT 5 FT UNOBSTRUCTED AREA =MOWER RUNOFF ALARMS i91INTENANCE AGREEMENT BUILDING AREA LOCATION CONFORMS RITE SXTE PLAN FINAL SITE ING CONTRACTOR OTC ARDS ARC 24 ABANDONMENT [ 49 ] TANK PUMPED 01/21/2010 [50] TANK CRUSHED a FILLED 01/21/2010 EID11166B2 Dade CRD DATE a 01/21/2010 DATE: 02/22/2010 Page 2 of 3 This certifies that the person named on the front of this card hassatisfied the requirements of Part III, Chapter 489, FloridaSitesfor registration as a septic tank contrat for 1sistered by the Department of F _ nsite Sewage Programs, to provide pr4ixidtftontrattecUdeitic tank services. Report Unlaw Tank Contracting: 1- 888 =993-9813 Registered Septic Tank Contractor JOE LEWIS 3075 NW 61 AVENUE FL 33023 - MIRAMAR JOE LEWIS SPECIALTY SEPTIC Business Authorization: 6E0081499 SR00815 Registration Expiration Date: September 30, 2010 ALEX SINK CHIEF FINANCIAL OFFICER EFFECTIVE DATE: PERSON: FEIN: BUSINESS NAME AND ADDRESS: LEWIS SPECIALTY SEPTIC LLC 1776 POLK ST #163 HOLLYWOOD FL 33020 SCOPES OF BUSINESS OR TRADE: 1- DRAINAGE DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 09 -06 2- SEPTIC TANKS 06/27/2008 EXPIRATION DATE 06/27/2010 LEWIS JOE JR 262847579 06-27 -2008 STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION * * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. IMPORTANT: Pursuant to Chapter 440 . 05114), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05113), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation Of, at any lime after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The 'department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. QUESTIONS? (850) 413 -164 PLEASE CUT OUT THE CARD BELOW AND RETAIN FOR FUTURE REFERENCE STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION CONSTRUCTION INDUSTRY CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW EFFECTIVE: 06/27/2008 PERSON: JOE LEWIS JR FEIN: 262847579 BUSINESS NAME AND ADDRESS: LEWIS SPECIALTY SEPTIC LLC 1776 POLK ST 0163 HOLLYWOOD, FL 33020 SCOPE OF BUSINESS OR TRADE: 1- DRAINAGE 2- SEPTIC TANKS EXPIRATION DATE: 06/27/2010 IMPORTANT O Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election I— under this section may not recover benefits or compensation under this D chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be R H exempt.. apply only within the scope of the business or trade listed on the notice of election to be exempt E Pursuant to Chapter 440.05(13), F.S., Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the person named on the notice or certificate no longer meet; the requirements of this section for issuance of a certificate. The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. CUT HERE * Carry bottom portion on the job, keep upper portion for your records, DWC -252 CERTIFICATE OF ELECTION TO BE EXEMPT RFVlcFn no-rig QUESTIONS? (850) 413 -1609 DATE ditialtDD/YYI ...4,-C7(3 INSURED CERTIFICATE OF LIABILITY INSURANCE 09 - 24 10 PRODUCER Admiral insurance, Inc. 17340 NW 27th Ave Miami Gardens, FL 33056 Phone (305)621-2939 Fax (305)621-1370 JOE LEWIS SPECIALITY SEPTIC LL 1776 Polk St #163 hillarni, FL 33056 COVERAGES INSURER F THE POLICIES OF INSURANCE LISTED HAVE BEEN ISSUED TO THE MUM) WANED ABOVE FOR TFIE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION Of ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAN BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT VALI. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR AMYL POLIVIEFFECTlitt PM= SKIIIMMON • LTR INSRD , LICY NUMBER .. Div .rglitNIMYYY./ .-. ciAle 1 _ _ L. _ ....Y TYPE OF II4SURANCE PO GENERAL LIABILITY , EACH OCC 100,000 V' COMMERCIAL GENERAL LIABILITY 08-12551 09 . 24;09 09/24110 L ROVED f!..ftg41ggPF-aocCIKence) _ _ 10000 MED E.XP (Anybrie person) A : Ami inagiy GENERAL AGGREGATE PRODUCTS - COMP!GP AGG CLAIMS MADE V OCCUR GEN'L AGGREGATE LIMIT APPLIES PER POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON OWNED AUTOS COMBINED SINGLE LIMIT if4I7a#K109 ROILY INJURY JPet BOI3ILYINJURY • Ter:accident) PROPERTY EiAMAGE (per accident) GARAGE UABILITY AUTO.ONL.1Y- .EA ACCIDENT ANY AUTO EXCESS/UMBRELLA LIABILITY OCCUR CLAMS MADE DEDUCTIBLE RETENTION $ • WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR 1 PARTNER t EXECUTIVE OFFICER 1 MEMBER EXCLUDED/ If yes, describe under SPECIAL PROVISIONS .below OTHER CERTIFICATE HOLDER ACORD 25 (2001/08) OF DESCRIPTION OF OPERATIONS FLOCA11ONS / VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS MIAMI SHORES VILLAGE BUILDING DEPARTMENT 10050 NE 2ND AVE. MIAMI SHORES FL. 33138 Th$ ERflFtCATE:tSISSUED D AS N-MAT'TgR OFMIFORMATION ONLY ANO CONFEW NO RIGHTS WON The .- CERTIFICATE HOLDF4t loam OR ;AFFOR050. Y THE POUC1ES LOW THE ' AFFORDING COVERAGE ' *WC* INSURER A: AMERICAPI VEHICLE INSURER B • INSURER IfsISURER • INSURER E ea . Nat, CANCELLATION 0114ER THAN EA, ACC_ AUTO ONLY: AGG . _ • EACH: OCCURRENCE • AGGREGATE • WC STATU- OTH- . TORY LIMITS - ER Et. EACH ACCIDENT EL DISEASE EA EMPLOYEE EL. DISEASE .POLICY LIMIT 100,000 100,000 100,000 • SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUINGINSURER WILL ENDEAVOR TO MAIL 16 DAYS WRITTEN NONCE TO THE C.ERTIFICATE HOLDER fIANIED TO THE LE BUT FAILURE TO DO SO SHAU. IMP ANON OR LIABILITY OF ANY KIND UPON THE INSURER ABENtS OR REPR tfrATIVES. AUTINIRMED REPRESENT/0Ni - ANGELO R. LAVE4CHIA AuORD CORPORATION APPLICANT: James Regis Lego AGENT: Joe Lewis (Joe Lewis Specialty SEPTIC) PROPERT1 ADDRESS: LOT: 14 SUBDIVISION: 10 STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL 163 NW 100 St _Miami, FL 33150 Bonmar Park 3 3 1 [05] [06] [07] [09] (09] (01] [021 [033 [04] TANK INSTALLATION [10] [11] [12] [13] [14] [15] [16] [ [19] (19] [201 [21] FILL [ ] [223 [ 3 (25) [ ] [24] [ 3 (253 ] [ toNSTRUCTION [ FINAL SYsTEN CHECKED X ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CO TANK SIZE [1] 900.00 [2] TAME MATERIAL Concrete OUTLET DEVICE MULTI - CHAMBERED OUTLET FILTER Y V Zabel LEGEND 1 13- 075 -04fC3 WATERTIGHT LEVEL DEPTH TO LID DRAINFIELD INSTALLATION AREA [1] 225 DISTRIBUTION BOX NUMBER OF DRAINLINES DRAINLIN3 SEPARATION DRA,INLINE SLOPE DEPTH OF COVER ELEVATION [ A90VE SYSTEM LOCATION DOSING PUMPS I APPROVED 1 [ AGGREGATE SIZE AGGREGATE EXCESSIVE FINES AGGREGATE DEPTH / EXCAVATION MATERIAL ITT. FILL AMOUNT FILL TEXTURE EXCAVATION DEPTH AREA REPLACED REPLACEMENT MATERIAL Comments: Comments are on page 2. (mcplaaanfen of Violatioae on lo1 QWiag page) N 2. (2] SOFT HEADER X 1, 4,00 2, BELOW I / DISAPPROVED ]: / DISAPPROVED 1: BLOCK: 4 ID #: 11- 3101- 023 -0310 ] ffiK 50'40 DH 4016, 10/97 (Previous Editions May Be Used) EM Databus v 1.0.1 AP848f163 SETBACKS (27] (293 [293 [30] [31] [32] [33] [34] [35] (37] (38] (39] Ronal9 E Cove (Duda County Envlromnenlal HBafth) E Cave made County Environmental Woo SURFACE WATER DITCHES PRIVATE WELLS PUBLIC WELLS IRRIGATION WELLS POTABLE WATER BUILDING FOUNDATIONS PROPERTY LINES OTHER FILLED / MOUND SYSTEM [36] DRAINFIELD COVER SHOULDERS SLOPES STABILIZATION ADDITIONAL INFORMATION [40] [41] [ [43] 1441 [ [46] [d [ 2101116682 APPLICATION # :A P948863 PERMIT #: 13- SC- 1116582 DOCUMENT #1F1777385 DATE PAID: 01/15/2010 Dade FEE map :200.00 RECEIPT ]# :1 -P I D- 1220239 CTED. 80 5 tank 5 UNOBSTRUCTED AREA STORMRATRR RUNOFF ALARMS MAINTENANCE AGREEMENT BUILDING AR LOCATION CONFORMS WITH SITE PLAN FINAL SITE ING CONTRACTOR OTHER ARDS ARC 24 ABANDONMENT (49] TANK PUMPED 01/21/2010 [50] TANK CRUSHED b FILLED 01/21/2010 CND DATE: 0121/2010 CHID AT 02/22/2010 Page 2 of 3 FT FT FT FT FT FT FT FT FT 400 /L00I1 XHJ OL :LL OLOZ /ZZ /ZO Violation Number S00/Z00 fj STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL Comment Da 4016, 10/97 (Previous Editions May Sa Used) EH 0sWino v 1.0.1 AP948884 2101116553 APPLXCATIOM # 1 AP948864 PERbro #: 13- SC- 1116583 aoc l r #: F1778779 DATE P ,01/15/2010 sus PAID : 80.00 RECEIPT # :13 -PI D 1220237 Pages 2 of 3 XVJ OL :Lt 0602 /ZZ /ZO BUILDING PERMIT APPLICATION FBC 20 Permit Type: PLUMBING Owner's Name (Fee Simple Titleholder) ES Owner's Address / 3 /v e.. to c, s City 1 ; r. , S /•%S State F /. Tenant/Lessee Name Email Job Address (where the work is being done) City Miami Shores Village County Miami -Dade Zip 3 3 /J z' FOLIO / PARCEL # l/ — 3 / O I —6.3/0 Is Building Historically Designated YES NO Flood Zone Contractor's Company Name Jo Ltc. e s. . 5p ) . / 7 , 7 , s.crelk TiaNOirroafr-e_ 78 *Sr.- i n Phone # 3 ° J (6 2 7Y 7 Contractor's Address 30 7S S / 4 /In City n 't i/d.Ol. or.- Qualifier Name State Certificate or Registration No. Soft 00 Y) .S Y ? Certificate of Competency No( Contact Phone 3 05 - t G 2 '" ?St? 9 E -mail Architect/Engineer's Name (if applicable) Submittal Fee $ Zip 3 J ez Le c.. e-. Phone# Miami Shores Village Building Department 10050 N.E.2nd Avenue, Miami Shores, Florida 33138 Tel: (305) 795.2204 Fax: (305) 756.8972 INSPECTION'S PHONE NUMBER: (305) 762.4949 Permit Fee $ /1-3 tiw /o O s f State J=/ Permit No. Master Permit No. Zip 3 3 /S® Phone # , . Phone # OV/ VuO -IC Value of Work For this Permit $ ®1) ''• Square / Linear Footage Of Work: 2 2 s S5 Pt Type of Work: ['Addition. ['Alteration ONew 'epair/Replace El Demolition Describe Work::. /`/ev S y S T4"k a.. r H,',✓ �;'c /c� :/7 (cr17, vPF $ 3 0(:) CO /CC $ Notary $ Training/Edtication Fee $ 1 VV Scanning $ ' Radon $ DPBR $ Bond $ Double Fee $ Violation date: Structural Review. $ TotaPFee Now Due $ 4) J. CO Technology Fee $ 4 See Reverse side -+ JAN 2 2010 ,Bonding Company's Name (if applicable) Bonding Company's Address City Mortgage Lender's Name (if applicable) Mortgage Lender's Address City State !, Zip Application is hereby made to obtain a permit to dd'' 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 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 Iiof 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 f or 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 fed will be charged. gnature Signature • Owner or Agent The foregoing instrument was acknowledged before me this day of JQYIU(Wy , 20 IV , by JO WC.S who is • ersonally know)o me or who has produced * * * * ** APPROVE (Revised 07 /10 /07)(Revised 06/10/2009) State Zip 0 Contractor The foregoing instrument was acknowledged before me this 22 day of JA -s✓• , 20 /0, by J ®e L ee„ s , who isle sonally known to me or who has produced �'Icc, i � !/as Q�cation and who did take an oath. Sign: Print: R. Diaew j--/acvo, -6 My Commissien-Frx is �, 2O 1 w 01:J As identification and who did take an oath. NOTARY PUBLIC: tO224s R.D F', < ,.WOR7_;: ON # DDSp5875 ootarry tern Engineer • L� °� i/ 0118 ans;Exafniner Zoning • Clerk checked 'Return to: Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 'Bill To I JAMES REGIS LEGO 163 NW 100 ST MIAMI SHORES, FL 33150 -1205 Date 01/22/2010 02/08/2010 01/22/2010 01/22/2010 02/08/2010 02/08/2010 01/22/2010 01/22/2010 Tuesday, February 16, 2010 Fee Name Submittal Fee Submittal Reversal Fee CCF Education Surcharge Permit Fee - Additions /Alterations Bond Type - Contractors Bond Scanning Fee Technology Fee Invoice Miami Shores Village 10050 N.E. 2nd Avenue Miami Shores, FL 33138 -0000 Phone: (305)795 -2204 Fax: (305)756 -8972 For Inspections please call: (305)762 -4949 Invoice Number: Invoice Date: Permit Number: Bond Number: PL -1 -10 -36874 January 22, 2010 PL -1 -10 -108 1924 'Comments: Fee Type Fixed Fixed Calculated Calculated Percentage Fixed Fixed Calculated Total Fees Due: Fee Amount $50.00 ($50.00) $3.00 $1.00 $350.00 $300.00 $3.00 $4.00 $661.00 Payments Date Pay Type 01/22/2010 Check 02/16/20V Cash Check Number 1798 Amount Paid $50.00 $311.00 Change $0.00 $0.00 Total Paid: $361.00 Total Due: $300.00 • 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 Statues. Such proceedings are govemed 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 altemative 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. CONSTRUCTION PERMIT FOR: OSTDS Repair APPLICANT: James Regis Lego PROPERTY ADDRESS: 163 NW 100 St LOT: 14 PROPERTY ID #: 11- 3101 - 023 -0310 SYSTEM DESIGN AND SPECIFICATIONS D R A I N F I E L D 0 T H E R STATE OF FLORIDA DEPARTMENT OF HEALTH DATE PAID: ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #: DOCUMENT #:PR796094 FILL REQUIRED: [ 0.00] INCHES THIS PERMIT IS NOT FO N(s). Miami, FL 33150 BLOCK: 4 SUBDIVISION: BonmarPark EXCAVATION REQUIRED: [ 24.00] INCHES SP ECIFICATIONS BY: PEDRO N OSPINA TITLE: - Legacy v 1.1.4 sP948863 SE805246 PERMIT # -SC- 1116582 APPLICATION #: AP948863 [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 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. T [ 900 ] GALLONS / GPD Septic CAPACITY A [ 0 ] GALLONS / GPD CAPACITY N [ 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] K [ ] GALLONS DOSING TANK CAPACITY [ ]GALLONS @[ ]DOSES PER 24 HRS #Pumps [ ] [ 225 ] SQUARE FEET SYSTEM [ 0 ] SQUARE FEET SYSTEM TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] CONFIGURATION: [X] TRENCH [ ] BED [ ] LOCATION OF BENCHMARK: F.F.E.: 13.2' NGVD ELEVATION OF PROPOSED SYSTEM SITE [ 26.40 ] [I INCHES I/ FT ] [ ABOVE A BELOW b BENCHMARK /REFERENCE POINT BOTTOM OF DRAINFIELD TO BE [ 50.40 ] [I INCHES 1 FT ] [ ABOVE A BELOW b BENCHMARK /REFERENCE POINT 1— Install 900 gal. category-3 septic tank equipped with an approved filter. 2 -The licensed contractor installing the system is responsible for installing the minimum category of tank in accordance with sec. 64E- 6.013(3)(f). 3- Install 225 sf of drainfield in trench configuration. 4- Perimeter of excavation area shall be at least 2 ft wider and longer than the proposed absorption trench. 5 -Invert elevation of drainfield to be no less than 9.50' NGVD 7. Bottom of drainfield elevation to be no less than 9.00' NGVD. APPROVED BY: TITLE: Dade CHD Pedro N °spina DATE ISSUED: 01/19/2010 T a gititi, ___ COtiW D P /2010 DE ti1Y..'�I� DH 4016, 10/97 (Previous Editions May Be Used) Page 1 of 3 I F € £ s 1 . j ., i r . :.... L. l s 1 . } ..... . ., l :.. i F 'f.. r. € d 1 e 4 a . i ,. x � 1 h t �' � A 3< i ' � � _. �"^ #• s � 7 €i ...,, �- £-�� ygq`` � ' [ �^T: 'b"""p _ "Y':'°d :^^•' ��^€"'., t _B 'Y.""�"">"._ F t s ii- t .....g„ •3 � 3 "' � 3 € `'°`a� i` � € 4 .d �_ 4- .e. �'f� �" $ £.£ F� g`"'"'y "9 '""` - ".v • I .P-.. L....„. J '>'p -" y ,. €y� '�:"'",�" $ q �«.. „„„ • 4 i- } '}-"`�"" -� �"- � -S 7.. _ i � � `_..� — g� --- y=- .y -r'.,€ g ¢ - ,� - :a> -b t ._ �... ^$. ✓� £�+� y� � - .,.5 �:. �,.�£ :.,,�, 1.__1 „6e.. 1 1� S � �# � .` � £ m.� i p � N 7 ' F _ �# l )��- .'W...�:.M >_ �" ""#- €.......� 6, € � ..�.... y3� y�.'^� T_ �e �.»,2 - � 3 1 { # # rt .....d... ....H... t - .,:...' {�„ -... .. �v. y w.:. �.�.� .wa .ts. -1. -i kcr..�. -,.�.. aw.n _ , .&.:%�- .✓e��:4. �:�«.��>:>�:wdam... :cm�+.3- .-m+.w � �� _:.. � .,,, -.... � � �� • . DEPARTMENT STATE OF FLORIDA APPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION PER Permit Application Number PART II - SITE PLAN Scale: Each block represents5 feet and 1 inch = -! Notes: o 1C43 I ace 00 / she S : 3 C +aV Di i ►°� --e t d - 1� n K. 411 - 1 - 4 k n 1- 460 7-2-rd -1 k t Site Plan submitted by: Plan Approved By X411■ m-e4 4 00 Signature Not Approved I `(5 t° C: 7g r( Title Date CouniyHialth Department ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT DH 4015,10!96 (Replaces HRS•H Form 4015 which may used) (Stock Number:5744-002-4015-6) Page 2of3