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PL-10-1403BUILDING PERMIT APPLICATION FBC 20 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 Type: PLUMBING r� ,(,� OWNER: Name (Fee Simple Titleholder): l e-; ( .' G G L f Phone#: Address: q G mot, e City: 444 ` .$ `i yveS State: Ft Zip: 33 / 3 Tenant/Lessee Name: Phone#: 907 6 b 2-73 V7 Email: JOB ADDRESS: o q J C J P"19 n c 6 Master Permit No. City: Miami Shores County: Miami Dade Folio/Parcel#: 11 — 3 A. P C 6 1 3 3 %p Ot) Is the Building Historically Designated: Yes NO irk Flood Zone: CONTRACTOR: Company Name: f/�a�(,ry ii0d /e1 )'4 " jZ Phone#: 7$ 4 ) 4 i IO P Address: 9.5 60 N 7 a l R I/ -e City: D 0-1:4-/ S te: / Zip: 3 3 MO Qualifier Name: � L'L A', L'l /end? Z." Phone#: State Certification or Registration #: ( s #: Ft 0 7 65 Certificate of Competency #: Contact Phone#: CI y J q '° L1 i' Email Address: --/e il a /"/ ? /IGiAA O'I'L ( - C av DESIGNER: Architect/Engineer: Phone#: Value of Work for this Permit: $ ) 2,000- Square/Linear Footage of Work: Type of Work: °Address °Alteration °New kepair/Replace °Demolition Description of Work: R. 1 p iA-e e- c i--; L ' �n°I k ✓l" efi/6 of T e// 1; kV e 124 eb I e— `F *Act/ I ECERCED AUG 0 4 zoo • Permit No. ) 0 1.403 Zip: 33t3S *************************************** F************* * * * * * * * * * * * * ***** * * * * * * * * * * * * ** Submittal Fee $ Permit Fee $ CCF $ CO /CC $ Scanning Fee $ Radon Fee $ DBPR $ Bond $ Notary $ Training/Education Fee $ Tec Fee $ Double Fee $ Structural Review $ TOTAL FEE NOW DUE $ 42' 0. Si o lY�l . REPLACE SEPTIC TANK AND DRAINFILED AND SEWER LINE CONNECTION BETWEEN THE HOUSE AND THE TANK TANK CAPACITY 900 GAL. DRAINFIELD 300 SQ FT Passed El--,,,, Inspector Comments Failed Correction Needed Re- Inspection Fee No Additional Inspections can be scheduled re- inspection fee is paid. until Inspection Number: INSP - 149707 Permit Number: PL -8 -10 -1403 I Inspection Date: August 11, 2010 Inspector: Hernandez, Rafael Owner: HART, NEIL Job Address: 295 GRAND CONCOURSE Miami Shores, FL 33138- Project: <NONE> Contractor: ROTO ROOTER SERVICES COMPANY Building Department Comments August 11, 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 Type: Plumbing - Residential Inspection Type: Final Work Classification: Septic Phone Number (305)962 -4547 Parcel Number 1132060133600 Page 1 of 1 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 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 reyaspection fee will be charged Signature / %J1 V' . i v Signa Owner or Agent The foregoing instrument was acknowledged before me this day of , 20 k 0, by .....W o • ' who is personally known to me or who has produced t/ As identification and who did take an oath. • 0 4 0 'it Notary Public State of Florida Idell Shorft Aq �Q My Commission DD783020 NOTARY P Sign: Print: My Commission Expires: (Revised 07 /10 /07)(Revised 06/10/2009)(Revised 3/15/09) Contractor The foregoing instrument was acknowledged before me this 5 day of direly, 200 by 9 hrleAr G 5o , who ispersonallv known to me or who has produced as identification and who did take an oath. NOTARY PUBLIC: Roger Grosso Fi of c o* Expires 829898 es 110/09/2012 ** * * * * * * * * * * * * * * ****** ax•*** ** ********** ** *** ** *** * *er a***** **** x******** s *+a**** a *** * * * * * ** * ** t * *** a*****,a*** APPROVED BY Plans Examiner Zoning Structural Review Clerk A RECORDED NOT E POOST�ED OC E SI C O M M EN C EMENT ' INSPECTION. 11111111111111111131111111111111111111111111 PERMIT NO.' 1 1O -. I 405 TAX FOLIO NO. Il "JZ 04 - 0 /3 - 3400 STATE OF FLORIDA: COUNTY OF MIAMI -DADE: THE UNDERSIGNED hereby gives notice that improvements will be made to certain real property, and in accordance with Chapter 713, Florida Statutes, the following information is provided in this Notice of Commencement. 1. Legal descri 2. Description of improvement: 8. In addition to himself, Owners designates the fol 713.13(1)(b), Florida Statutes. Name, address and phone number: Signature(s) of Prepared By Print Name Title/Office STATE OF FLORIDA COUNTY OF MIAMI -DADE The foregoing in By ❑ Individually, o ❑ Personally kn Signature(s) ofnOwn By 123.01-52 PAGE 3 12109 on of property and street/address: D- # t 2_g C CFN 2010RO -513179 OR Bk 27371 Ps 0021; (1Ps) RECORDED 07/30/2010 14:17 :53 HARVEY RUVIidr CLERK OF COURT MIAMI -DADE COUNTY, FLORIDA LAST PAGE Space above reserved for use of recardling office i .A e 3. Owner(s) name and address: Interest in property: b W vt Name and address of fee simple titleholder: 4. Contractor's name, address and phone number: c r54 - 4c4,..7 fir 5. Surety: (Payment bond required by owner from contractor, if any) Name, address and phone number: Amount of bond $_ 6. Lender's name and address: A'. ,_ A �? 7. Persons within the State of Florida designated by Owner upon whom notices or other documents may be served as provided by Section 713.13(1)(a)7., Florida Statutes, Name, address and phone number: lA gay i °L� C, WT' OF GADS 371 . , ,o Orginu, ?t to 10 0;;A, i On ed in Section HA 4, L. �J r.:t oiC.11w 9. Expiration date of this Notice of Commencement % , 4 :I ✓✓ e of recording unless a different date is specified) WARNING TO OWNER: ANY PAYMENTS MADE BY THE OWNER R THE EXP TION OF THE NOTICE OF COMMENCEMENT ARE CONSIDERED IMPROPER PAYMENTS UNDER CHAPTER 713, PART I, SECTION 713.13. FLORIDA STATUTES, AND CAN RESULT IN. YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. tozed8t k. cer/Director/Partner/Manag Prepared By e Print Name Title/Office 0-14.42. wled ed before me thi Z , day (SEAL) VERIFICATION PURSUANT TO SECTION 92.525, FLORIDA STATUTES Under penalties of perjury, declare that l have read the foregoing and that the facts stated in it are true, to the best of my knowledge and belief. O id for of identification: blic: e: orized Officer /Director/Partner /Manager who signer above: By THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT -WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR ADD't{ TYPE OF INSURANCE INSR POLICY NUMBER POLICY EFFECTIVE DATE (MMlDDlYYY1') POLICY EXPIRATION DATE (MMfOD(YYY11 A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY GLO 9379365 -06 04/01/2010 04/01/2011 EACH OCCURRENCE $ 2.000.000 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 500,000 CLAIMS MADE I X 1 OCCUR MED EXP (Any one person) $ 5,000 GENERAL X PERSONAL & ADV INJURY $ 2,000,000 GENERALAGGREGATE $ 6,000,000 AGGREGATE LIMIT APPUES PER POLtCY n PR n LOC PRODUCTS - COMP/OP AGG $ 5,000,000 A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS BAP9379363 - 06 (AOS) 04/01/2010 04/01/2011 COMBINED SINGLE LIMIT (Ea accident) $ 3,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE 7 LIABILITY ANY AUTO AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS 1 1 UMBRELLA UABIUTY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ A I WORKERS EMPLOYERS' ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER Mandatory PECIAL COMPENSATION AND LIABILITY Y/ N WC9379366 - 06 (AOS) 04/01/2010 04/01/2011 X I f A U - T T c.L EACH ACCIDENT $ 1,000,000 EXCLUDED? N IL DISEASE - EA EMPLOYEE $ 1,000,000 in NH) If yes, describe under PROVISIONS below =.L DISEASE - POLICY LIMIT $ 1,000,000 OTHER ACORD PRODUCER MARSH USA INC. 525 VINE STREET, SUITE 1600 CINCINNATI, OH 45202 Attn: Cincinnati .certrequest @marsh.com, Fax 212 - 948 -0785 400408 - RRSC -GAU W P -10 -11 00044 CERTIFICATE OF LIABILITY INSURANCE INSURED ROTO- ROOTER SERVICES COMPANY 1550 NORTHWEST 79TH AVENUE MIAMI, FL 33126 THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURER A: Zurich American Insurance Company INSURER B: N/A INSURER C: N/A INSURER D: INSURER E: DATE (MM/DDIYYYY) 03/29/2010 NAIC # 16535 N/A N/A COVERAGES LESIEXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS CERTIFICATE HOLDER CITY OF MIAMI SHORES 10050 NE 2ND AVE MIAMI SHORES, FL 33138 ACORD 25 (2009101) CLE- 002519556 -13 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. A Of Ma USA IncSENTATNE John F. Schultz © 1998-2009 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD DEVILKHOrli ( 11 r„,ituti UGC ® ' o � Gj�sLi� a o( 1:010)-0:040 . APPLICANT: -, j.7 AGENT: 4 ' • , y..- ..x, s' �y` - -r PROPERTY ADDRESS: 1 " �- — -- r �?' z .o LOT: BLOCK: / SUBDIVISION PROPERTY ID # = = = = = = = = = = = = = = = = = = = = = = = = — = = = = — = = = = = = = = = = CHECKED [X] ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. EXPLANATION OF VIOLATIONS / REMARKS: [ 1 TANK INSTALLATION [01] TANK SIZE [1] [2] [02] TANK MATERIAL [03] OUTLET DEVICE [04] MULTI - CHAMBERED [Y / N ] [05] OUTLET FILTER [06] LEGEND [07] WATERTIGHT [08] LEVEL [09] DEPTH TO LID DRAINFIELD INSTALLATION [10] AREA [1] T [2] SOFT [11] DISTRIBUTI9N BOX HEADER [12] NUMBER OF/ [13] DRAINLINE [14] DRAINLINE [15] DEPTH OF [16] [ [18] DOSING UMPS [19] AGGRE ATE SIZE [20] AGGRE o ATE EXCESSIVE FINES [21] AGGREGATE DEPTH FILL / EXCAVA ION MATERIAL [22] FILL MOUNT [23] FILL EXTURE [24] EXCA1 ATION DEPTH [25] AREA REPLACED [26] REPLACEMENT MATERIAL [ ] `� ✓� [ 1 r CONSTRUCT N [APPROVEDMISAPPROVED]• STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL -L. x EPARATION SLOPE COVER ELEVATIC�'N [ABOVE/BELOW] BM SYSTEM , OCATION FINAL SYST M [APPROVE /6TS4PPROVED]: DH 4016 (Page 2), 10/97 (Previous Editions May Be Used) Stock Number: 5744- 002 - 4016 -4 ( PT 1: Applicant PT 2: Installer /Contractor PT 3: Building Department PT 4: Health Department PERMIT NOM s DATE PAID FEE PAID: RECEIPT #• SETBACKS f [27] SURFACE WATER FT [28] DITCHES rl FT [29] PRIVATE WELLS i FT [30] PUBLIC WELLS / FT [31] IRRIGATION WELLS ! FT [32] POTABLE WATER LINES( FT [33] BUILDING FOUNDATION' FT [34] PROPERTY LINES 1 FT [35] OTHER 1 FT C FILLED / MOUND SYSTEM 1 [36] DRAINFIELD COVER / [37] SHOULDERS / [38] SLOPES I [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 9 [47] CONTRACTOR ' ewe [48] OTHER ABANDONMENT [49] TANK PUMPED Er/ / [50] TANK CRUSHED & FILLED `' / / CHD DATE U ' 0 CHD DATE. n ' 2 `�' ` / Page 2 of 3 Rendd APPLICANT: Joann Hart SUBDIVISION: TANK [01] [02] [03] [04] [05] [06] [0 [08] [09] FILL [22] [23] [2 [25] [26] CONSTRUCTION FINAL SYSTEM [ STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION INSPECTION AND FINAL APPROVAL AGENT: Roto Rooter PROPERTY ADDRESS: 295 grand concourse Miami, FL 33138 LOT: 1 CHECKED rxi ITEMS ARE NOT IN COMPLIANCE WITH STATUTE OR RULE AND MUST BE CORRECTED. INSTALLATION TANK SIZE [1] 1050.00 [2] TANK MATERIAL OUTLET DEVICE MULTI- CHAMBERED OUTLET FILTER Zabel LEGEND 1. 70-109-21DC3 WATERTIGHT LEVEL DEPTH TO LID DRAINFIELD INSTALLATION / EXCAVATION MATERIAL FILL AMOUNT FILL TEXTURE EXCAVATION DEPTH AREA REPLACED REPLACEMENT MATERIAL Comments: Comments are on page 2. APPROVED I I APPROVED I [I Y 1 / DISAPPROVED ]. (Explanation of Violations on following page) Polyethylene N 2. [10] AREA [1] 300 [2] SQFT [11] DISTRIBUTION BOX HEADER X [12] NUMBER OF DRAINLINES 1. 5.00 2. [13] DRAINLINE SEPARATION [14] DRAINLINE SLOPE [15] DEPTH OF COVER [16] ELEVATION [ ABOVE /I BELOW I]BM 40.80 [17] SYSTEM LOCATION [18] DOSING PUMPS [19] AGGREGATE SIZE [20] AGGREGATE EXCESSIVE FINES [21] AGGREGATE DEPTH / DISAPPROVED ]: BLOCK: 27 DH 4016, 08/09 (Obsoletes all previous editions which Incorporated: 64E- 6.003, FAC EH Database v 1.0.1 ID #: 11 3206 - 013 - 3600 AP974301 SETBACKS [2 [28] [29] [30] [31] [32] [33] [34] [35] FILLED / MOUND SYSTEM [36] [37] [38] [39] Ronald E Cave (Dade County Environmental Health) Ronald E Cave (Dade County Environmental Health) may not be used) APPLICATION # : AP974301 PERMIT #:13 -SC- 1271315 DOCUMENT #:F1800109 DATE PAID: /O 2 / 2010 FEE PAID: 200 . 00 RECEIPT #:13 -PID- 1435991 SURFACE WATER DITCHES PRIVATE WELLS PUBLIC WELLS IRRIGATION WELLS POTABLE WATER BUILDING FOUNDATIONS PROPERTY LINES OTHER DRAINFIELD COVER SHOULDERS SLOPES 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 Roto Rooter Roto Rooter (Rot [48] OTHER ARDS ARC 24 ABANDONMENT [49] TANK PUMPED 08/10/2010 [50] TANK CRUSHED & FILLED 08/10/2010 EID1271315 Dade CHD DATE : 08/09/2010 Dade 100 15 15 CHD DATE: 08/10/2010 Page 2 of 3 FT FT FT FT FT FT FT FT FT IMP •1 I BELOW • PEDRO N OSPINA or installing the system 3- Install 300 sf of Perimeter of excavation f drainfield to be no Tess IR HEALTH Dade APPLICANT: PROPERTY ADDRESS: LOT: 1 T A [ N [ K [ L 0 T E R D FILL REQUIRED: STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM CONSTRUCTION PERMIT FOR: OSTDS Repair Joann Hart PROPERTY ID #: 11- 3206 - 013 -3600 SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS 381.0065, F.S., AND CHAPTER 64E -6, F.A.C. DEPARTMENT APPROVAL OF SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME. ANY WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE T PERMIT APPLICATION. SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT ISSUANCE OF THIS PERMIT DOES NOT EXEMPT THE APPLICANT FROM COMP STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS 900 ] GALLONS / GPD Seotic O ] GALLONS / GPD O ] GALLONS GREASE INTERCEPTOR CAPACITY ] GALLONS DOSING TANK CAPACITY D [ 300 ] SQUARE FEET SYSTEM R [ 0 ] SQUARE FEET SYSTEM A TYPE SYSTEM: [x] STANDARD [ ] FILLED [ ] MOUND [ ] I CONFIGURATION: [ ] TRENCH [x] BED [ ] N F LOCATION OF BENCHMARK: F.F.E.: 11.50' NGVD. I ELEVATION OF PROPOSED SYSTEM SITE [ 14.40 ] [l INCHES If FT ] ( ABOVE E BOTTOM OF DRAINFIELD TO BE [ 49.40 ] [I INCHES FT ] [ ABOVE 1— Install 900 gal. category-3 septic tank equipped with an approved filter. 2 -The licensed contra is responsible for installing the minimum category of tank in accordance with sec. 64E- 6.013(3)(f) drainfield in bed configuration. 4- Install 12° of slightly limited soil under the bottom of drainfield. area shall be at least 2 ft wider and longer than the proposed absorption bed. 6 -Invert elevation than 7.88' NGVD. 7. Bottom of drainfield elevation to be no Tess than 7.33' NGVD.. THIS PERMIT IS NOT FOR ADDITION(s). SPECIFICATIONS =- APPROVED B P :. . N 08p DATE ISSUED: 08/03/2010 295 • rand concourse Miami, FL 33138 BLOCK: 27 SUBDIVISION: [ 0.00] INCHES EXCAVATION REQUIRED: [ 35.00] INC DH 4016, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E- 6.003, FAC v 1.1.4 APP [SECTION, TOWNSHIP [OR TAX ID NUMBER] CAPACITY CAPACITY [MAXIMUM CAPACITY SINGLE T ]GALLONS @[ ]DOSE EXPI AP974301 8E823005 PERMIT # -SC- 1271315 ICATION #:AP974301 DATE PAID: FEE PAID: RECEIPT #: UMENT #: PR818209 RANGE, PARCEL NUMBER] STANDARDS OF SECTION SYSTEM DOES NOT GUARANTEE CHANGE IN MATERIAL FACTS, APPLICANT TO MODIFY THE EING MADE NULL AND VOID. LANCE WITH OTHER FEDERAL, :1250 GALLONS] PER 24 HAS #Pumps [ ] BENCHMARK /REFERENCE POINT BENCHMARK /REFERENCE POINT S TION DATE: 11/01/2010 Page 1 of 3 CHD NOTICE OF RIGHTS A party whose substantial interest is affected by this order may petition fo administrative hearing pursuant to sections 120.569 and 120.57, Florida Statues. proceedings are governed by Rule 28 -106, Florida Administrative Code. A petiti administrative hearing must be in writing and must be received by the Agency CI Department, within twenty-one (21) days from the receipt of this order. The addr Agency Clerk is 4052 Bald Cypress Way, BIN # A02, Tallahassee, Florida 32399 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 constitute a waiver of your right to an administrative hearing, and this order shall order'. Should this order become a final order, a party who is adversely affected to judicial review pursuant to Section 120.68, Florida Statutes. Review proceedi governed by the Florida Rules of Appellate Procedure. Such proceedings may b by filing one copy of a Notice of Appeal with the Agency Clerk of the Department second copy, accompanied by the filing fees required by law, with the Court of A appropriate District Court. The notice must be filed within 30 days of rendition of an Such n for rk for the ss of the 1703. The his order will ecome a 'final • y it is entitled gs are commenced of Health and a peal in the he final order. ■ • • • • • a► • • • • • • • ■1111■ ■1111■ ■ ® ■1111=I ■■ 1111■■■■■ ■■ ■■f 1111■ PROPERTIES t P JAG HP Not Ap . ovecJ D ACROSS THE STREET THAT MAY AFFECT THE Scale: Each block re SYSTEM LOCATION resents Site Plan submitted by: SUNIL Plan A•. • By 5 fe STATE OF FLORIDA DEPARTMENT OF HEALTH APPLICATION FOR CONSTRUCTION PERMIT Permit Application N mber PART II - SITEPLAN 130' 09 -1043 ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH OH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, PAC (Stock Number: 5744 -002 - 4015 -6) WATER LINE WATER METER DRI ■ ■ ■ ■ ■ ■=r ■ ■ ■ [ I __1111■ ■1 11.%■ ■ ■■ IONE ®■■ _ ■ ■ ■ ■B % ■IiFili n :\ ■ ■ ■■%■■I■Mi■=11111111111E■1111111 ■NNIII■ " ■■ ■I■r1 ■ ■ �1 ■111= IMMI■ 111■i■•■■I ■1 1 NW gg =. A■i/■■ ■■1■■u111111 ■■= z ■ ■■Ii!�7NV .� / ■ /■■ /I Z I V . /Ifr_ ■% ■■■/A IMO LIEFIIIIIMIL APff_ / ■M rNIIIKMI■■■■ ■■■II /II■�I ■ MN IMMIEME10111111/%111111211111 RIM `fll / ■ ■ ■•% ■ ■1/1W ■■ - c 10.3 N 3V \.!■■■./■■./_■, P. / ■ ►`u •■ %•••■• % ►: !I__ ■■ ►■ %■■ ■/ ■ ■IWA ■ L16. MILIM■ ■ ■ ■02 1111 ■0■ ■ ■� ■ ■■ ■ ∎�■ •11/41111111111M111•111%111111 ■■■ Notes: THERE ARE NO P ON AD) Date 07/29/10 County Health Department DEPARTMENT Page 2of4