i 7 RECEIVED DEPARTHE ONT OF RE ALTH STATE OF FLORIDA 2009 DEC 24 AMI: 47 DEPARTMENT OF HEALTH : OFFICE GF THE DEPARTMENT OF HEALTH, nN ANi, TD) FIRE CLERK Petitioner, } } -COY | KB L vs. DOH Case No.: 2009- MARTIN A. GUFFY, Respondent. / ADMINISTRATIVE COMPLAINT WY 4 QyP 162 Nature of the Case YOU ARE HEREBY NOTIFIED that this is an administrative actioft: This Giise arises from Respondent’s unlawful acts and practices and failure to comply with Section” 481. 0065 Florida Statutes, Chapter 489 Part HI Florida Statutes and Chapter 64E-6 Florida Administrative Code. This action is authorized pursuant to Sections 381.0061 and 489.556 Florida Statutes, and Rule 64B-6.022 Florida Administrative Code that govern disciplinary actions against registered septic contractors. Factual Allegations and Law as to All Counts 1. The Petitioner, State of Florida, Department of Health, is the administrative agency of the State of Florida charged with the duty to enforce the provisions of Chapter 381 Florida Statutes, Chapter 489 Part III Florida Statutes and the applicable rules contained in Chapter 64E-6 Florida Administrative Code. : 2. The Respondent, Martin A. Guffey, is a registered. septic tank contractor, Registration Number SR0971273. He is authorized to provide septic tank contracting services through the corporation Martin Septic Service, Inc., Authorization Number SA0071446. 3. The Respondent advertises and holds himself out to the public as a septic tank contractor and engages in the practice of septic tank contractor services in at least Sarasota and Charlotte County. The Respondent is permitted to provide septage collection, hauling and discharge services via an operating permit issued by the Sarasota County Health Department. See Permit attached and incorporated herein as Attachment “A”. The Respondent’s permit allows him to discharge waste at the Charlotte County Utilities Waste Receiving Facility. 4. Florida law prohibits the installation, repair, alteration, modification, abandonment, or replacement of septic systems without first obtaining a permit from the Department. See Florida Statute 381.0065(4) and Florida Administrative Rule 64E-6.003(1). The Department requires permit applicants to have all septic tanks pumped by a licensed septic tank contractor service to determine the volume and structural integrity of the tank before obtaining a permit. This information must be certified to by the septic tank contractor on DH Form 4015. . . 5. Charlotte County requires all septic tank contractors who are permitted to provide septage collection, hauling and discharge services to fill out and submit a Transport Waste Hauler Manifest prior to discharging each load of pumped waste into the county water treatment facility. The completed manifest must include the address of the property from where the waste originated. Therefore, there should be a corresponding manifest documenting the permit- required initial septic tank pump-out for each septic permit application certification in Form DH 4015. 6. As part of an investigation into whether septic tank contractors were providing true and accurate certifications of the permit-required initial septic tank pump-outs, a Charlotte County Department of Health inspector pulled all septic system permit applications submitted to the Department between June 1, 2009 and September 30, 2009. The inspector then pulled all Charlotte County Transport Waste Hauler manifests for the relevant time periods to verify the septic tank contractors had in fact conducted the permit-required initial pump-outs of the septic systems as they had certified. COUNT I 7. On July 23, 2009, the Department received an Application for a permit to repair septic system, submitted by the property owner’s agent, Respondent Martin A Guffy, Martin Septic Services, Inc.; for an existing residence located at 20282 Albury Drive, Port Charlotte, Florida. See Application and Permit attached and incorporated herein as Attachment “B”. As part of the Application, the Respondent completed Form DH 4015. The Respondent certified on this form that he pumped and inspected the septic tank located at 20282 Albury Drive on June 24, 2009 and that it was structurally sound. See Certification attached and incorporated herein as Attachment “B-1”. Additionally, the Respondent signed and dated the form entitled “Attachment A - Instructions For Completing and Submitting Your Septic Permit Application”, which again instructed him to pump the septic tank to determine volume and structural integrity. See Attachment A - Instructions attached and incorporated herein as Attachment “B-2”. The Department subsequently issued the repair permit. 8. A review of the pulled manifests submitted by septic tank contractors for the relevant time period revealed the Respondent never filled out and submitted a Transport, Waste Hauler Manifest for the initial, permit-required septic tank pump-out for the property located at 20282 Albury Drive, Port Charlotte, Florida. See Respondent’s Transport Waste Hauler Manifests dated June 24, 2009 through July 4, 2009 attached and incorporated herein Composite Attachment “C”. The lack of such a manifest evidences the Respondent falsified his certification on DH Form 4015 that he pumped the septic tank and determined its volume and structural integrity. Had the Respondent pumped the septic tank on June 24, 2009 as he certified, there would be a corresponding Transport. Waste Hauler Manifest for the property located at 20282 Albury Drive showing the pumped waste had been discharged into the county water treatment facility on or about June 24, 2009. 9. On or about July 30, 2009, a Charlotte County Department of Health inspector spoke to one of the Respondent’s employees, who confirmed the Respondent did not conduct the initial permit-required septic tank pump-out on June 24, 2009 as he had certified on DH Form 4015. The employee stated they certified the Albury Drive septic tank was structurally sound without ever inspecting the tank because the homeowners told them the tank had been pumped recently. The employee stated they never verified the information provided by the homeowners. 10. On or about August 10, 2009, the same inspector spoke with the Respondent in the presence of other Charlotte County. Health Department employees and confronted him about the false certification. The Respondent admitted he had been taking the homeowner’s word that the septic tank had been pumiped and not conducting the initial permit-required septic tank pump- out and inspection. . 11. The Respondent falsified and/or provided untrue statements on Health Department Form 4015. The Respondent certified that he had pumped the septic tanks located at 20282 Albury Drive, Port Charlotte, Florida when in fact, the Respondent did not pump the tank. The Respondent also certified the tank was structurally sound, when in fact, the Respondent had not pumped the tank to properly inspect for structural soundness. The Respondent’s information provided in the signed certification on Form 4015 contains false, misleading and untrue representations and subjects the Respondent to the discipline mandated in Rule 64E-6.022(1)d,) Florida Administrative Code, which is a letter of warning or a fine up to five hundred dollars ($500) for the first violation. The Department hereby imposes a fine of five hundred dollars ($500) for this violation against the Respondent. Alternatively, these acts and practices amounted to gross negligence, incompetence, or misconduct in violation of Rule 64E- 6.022(1)(1)1, Florida Administrative Code. The Respondent’s actions subject the Respondent to the discipline in Rule 64E-6.022(1)(), which is a letter of warning or fine up to five hundred dollars ($500) for the first violation. The Department hereby imposes a fine of five hundred dollars ($500) for this violation against the Respondent. COUNT I 12. On September 8, 2009, the Department received an Application for a permit to repair septic system, submitted by the property owner’s agent, Respondent Martin A Guffy, Martin Septic Services, Inc., for an existing residence located at 9320 Anita Avenue, Englewood, Florida. See Application and Permit attached and incorporated herein as Attachment “D”. As part of the Application, the Respondent completed Form DH 4015. The Respondent certified on this form that he pumped and inspected the septic tank located at. 9320 Anita Avenue on August 14, 2009 and that it was structurally sound. See Certification attached and incorporated herein as “Attachment D-1”. Additionally, the Respondent signed and dated the form entitled “Attachment A - Instructions For Completing and Submitting Your Septic Permit Application”, which again instructed the Respondent to pump the septic tank to determine volume and structural integrity. See Attachment A - Instructions attached and incorporated herein as Attachment “D-2”. The Department subsequently issued the repair permit. 13. A review of the pulled Charlotte County Transport Waste Hauler Manifests submitted by septic tank contractors for the relevant time period revealed the Respondent never filled out and submitted a Transport Waste Hauler Manifest for the initial, permit-required septic tank pump-out for the property located at 9320 Anita Avenue, Englewood, Florida. See Respondent’s Transport Waste Hauler Manifests dated August 14, 2009 through August 24, 2009 attached and incorporated herein Composite Attachment “E”. The lack of such a manifest evidences the Respondent falsified his certification on DH Form 4015 that he pumped the septic tank and determined its volume and structural integrity. Had the Respondent pumped the septic tank on August 14, 2009 as he certified, there would be a corresponding Transport Waste Hauler Manifest for the property located at 9320 Anita Avenue showing the pumped waste had been discharged into the county water treatment facility on or about August 14, 2009. 14. . The Respondent falsified and/or provided untrue statements on Health Department Form 4015. The Respondent certified that he had pumped the septic tanks located at 9320 Anita Avenue, Englewood, Florida when in fact, the Respondent did not pump the tank. The Respondent also certified the tank was structurally sound, when in fact, the Respondent had not pumped the tank to properly inspect for structural soundness. The Respondent’s information provided in the signed certification on Form 4015 contains false, misleading and untrue representations and subjects the Respondent to the discipline mandated in Rule 64E-6.022(1)(k) Florida Administrative Code, which is a letter of warning or a fine up to five hundred dollars ($500) for the first violation. The Department hereby imposes a fine of five hundred dollars , ($500) for this violation against the Respondent. Alternatively, these acts and practices amounted to gross negligence, incompetence, or misconduct in violation of Rule 64E- 6.022(1)(1)1, Florida Administrative Code. The Respondent's actions subject the Respondent to the discipline in Rule 64E-6.022(1)()), which is a letter of warning or fine up to five hundred dollars ($500) for the first violation. The Department hereby imposes a fine of five hundred dollars ($500) for this violation against the Respondent. REQUEST FOR RELIEF ; Wherefore, the Department of Health hereby imposes an administrative fine in the total amount of One Thousand Dollars ($1,000) against the Respondent, Martin A.Guffy, Registration . Number SR0971273. The Total Fine imposed herein, to date, being One Thousand Dollars ($1,000) is due and payable within 21 days of receipt of this Complaint to the Charlotte County Health Department, Attention Herman Velasco, Environmental Administrator, 18500 Murdock Circle, Port Charlotte, Florida 33948. Done this 10 %4ay of December, 2009, by the Department of Health, Charlotte County Health Department. STATE OF FLORIDA ~ DEPARTMENT OF HEALTH DENISE DUQ Florida Bar #00565921 Senior Attorney 2295 Victoria Avenue, Room 206 _ Fort Myers, Florida 33901 (239) 461-6130 (239) 461-6102 facsimile CERTIFICATE OF SERVICE I hereby certify that the true and original Administrative Complaint herein was furnished via FedEx Tracking #1482 (O13 [750 to Martin A Guffy, Martin Septic Services, Inc., 2308 Tropicaire Boulevard, North Port, Florida 34286; and a true and correct copy herein was furnished via United States Mail to, Albert J. Tiseo, Jr. Esquire, 701 JC Center | Of da cember, 2009. Court, Suite 3, Port Charlotte, Florida 33954, NOTICE OF RIGHTS TO APPEAL A party whose substantial interest is affected by this order may petition for an administrative hearing pursuant to sections 120.569 and 120.57, Fla. Stat. Such proceedings are governed 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 FL 32399-1703. The Agency Clerk’s facsimile number is 850-410-1448. : Mediation is not available as an alternative remedy. ; Your failure to submit 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, Fla. Stat. 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. Co. STATE OF FLORIDA C.. om Heay, DEPARTMENT OF HEALTH @ RECEIVED % ® J od APPLICATION FOR: a NOV 1 0: 2009 3 SEPTAGE DISPOSAL SERVICE PERMIT Z s TEMPORARY SYSTEM SERVICE PERMIT & AD SEPTAGE TREATMENT & DISPOSAL FACILITY % MIN Ny SEPTIC TANK MANUFACTURING APPROVAL Ve . iP : . Wironmne Authority: Chapter 381,F.S. icat it Number,__ 200.057 PUMPER Cha Non ase 6 NS ‘ Fr Application’Permt Appl cao 6 tor: i Septage Disposal Service__X_Temporary System Service: Septage Treatment Facility: eptic Tank Manufacturing: GENERAL INFORMATION Business Name: Martin Septic Service Phone Number, (941 1429-6842 Gertinicate of Aufhafzation for Registration 43 Plum ing icense Wri! 22, L Phone Number:__{941 = SEPTAGE DISPOSAL SERVICES ‘ . , Vehicle Id. Number/_leense Plate Numbe ruck Gallonage Capacity Counties of O tion Inspected & ‘aved INPALUOKAGN4T? Od NBIOTN | ook CaNgnage Capaciy asota Yes: Ror eroved “BINPALUOXSYNEO 1470 —N219 — Yes: —X-No: LAPALWE RUNS TCP Le (Taso rit i — No: List equipment used in the operation of this B husingas necessary for the sanitary pumping, transport, and disposal of septage___ pproved: Yes_X No Disposal Method: Wastewater Treatment Plant:___X___Locatian:_Cha A Approved: Yes. OL 9 Utilities, Land.Application Site: Lacation=—_. . aa Approved: Yes_No. Satony Landfill: Location: Approved: Yes__No___ Owner/Operator of Disposal Site: Chad a Utilities Are facilities availahia at the dis; r ihe proper ant and stabilization of septage and grease: @8. o_ (f No, location where the waste will be stabilized: By what mathod: Facility wil be under the ragulation oF DER, ARS Both Directions to Disposal Site: ~ : Provide a letter of authorization from the operator of the disposal site allowing your business to dispose of septage at that location. If : restrictions have been placed an your business by the operator of the pe at the resigns must be specified in the letter. TEMPORARY SYSTEM SERVICES (INCLUDES PORTABLE TOILETS AND HOLDING TANKS) Back up Service Available: Yes, No. tf Yes, Name of Back Up Service: : Address: _ Phona Number, Truck Gallonage Capacity Vehicle ld, Numbar/License Plate Number Waste Water Counties of Operation = Inspected & Approved Disposal Site: Approved: Yas:No:__ Provide a letter of authorization fram the operator of the disposal site allowing your businass to dispose of portabje ta tank wastes at that location. If restichiang have been placed on your businaes by the operator af the disposal faclty, the restrictions must be specified in the letter. Page 1 of 2 toilet and/or holding — my ATTACHMENT aA 4 OPERATING PERMIT For: OSTDS - Service and ATU Maintenance, Disposal Servicy, ' Billing ID: 58-B1D-1210964 Issued To: Martin Septic Service Permit Number: 58-Q3-00032 2308 Tropicaira Blvd County; 58 -Sarasota North Port, FL 34286 : Issue Date; 01/01/2010 Permit Expires On: 12/31/2010 The facility shown above has been inspected by a duly authorized rapresentative of the Department of Health, and was found in conformance with those rules promulgated by the department under the authority of Chapters 361, 386 and 489 Part Ili, Florida Statutes, and eet forth in Rule 64E-6, Florida Administrative code. This parmit grants authority to operate the abave referenced facility, service, or system in conformance with department rules and the conditions of operation shown below. This permit is revovable, upon service of notice, when it is determined by the department that the operational conditions and department standards are nat being maintained. tssued by: Sarasata County Health Department 1301 Cattlemen Rd, Sarasota, FL 94232 DO NOT DETAGH HERE (Non-Transferable) 00 NOT SEPARATE FROM OPERATING PERMIT ' CONDITIONS OF OPERATION For: OSTOS - Service And ATU Maintenance, Disposal Service, _ Billing ID; 58-BID-1210964 Permit Number: 58-Q3-00032 \ssued To; Martin Septic Service ; Permit Expires On: 12/31/2010 The operating permit for the facility shawn above has been issued with the following conditions of operation: OH-1013 (03/97) DISPLAY OPERATING PERMIT AND CONDITIONS OF OPERATION IN A CONSPICUOUS PLACE (Non-Transferable) DETACH HERE - RETAIN THIS PORTION FOR YOUR REGORDS RECEIPT 2 . Billing ID: 58-BID-1210964 For: OSTDS - Service And ATU Maintenance, Disposal Service, Permit Number: §8-Q3-00032 Issued To: Martin Septic Service County: 58 - Sarasota 2308 Tropicaire Bivd Issue Date: 01/01/2010 North Port, FL 34286 . Amount Pald; 76.00 Date Paid: 11/10/2009 CheckNumber; 50944 Receipt Number: 58-PID-1206469 Mailed To: Martin Septic Service, inc. Operator 1D: DerasierOM 2308 Tropicaire Bivd Fee paid by: Martin Septic Service North Port, FL 34286 issued By: Sarasota County Health Department RETAIN FOR YOUR RECORDS CONSTRUCTION PERMIT FOR: a ny ® OF 345A permir #:08-SM-996650 appLication #: AP930420 e RIDA DATE PAID: oF NT OF HEALTH ro SEWAGE TREATMENT AND DISPOSAL FEE no: lla RECEIPL #: pocmen #:PR7B0516 OSTDS Repair APPLICANT: Andrea Telman, Tr PROPERTY ADDRESS: 20282 Albury Dr__ Port Charlotte, Fl 33952: 6 BLOCK: 464 SUBDIVISION: PC Sec 18 Lor: PROPERTY ID #: 402216184001 (SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] [OR TAX ID NUMBER] STANDARDS OF SYSTEM MUST BE . CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND SECTION 381.0065, F.S., wo [errr 64E~6, FVA.C. DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC PERTOD: OF TIME. ANY, CHANGE IN MATERIAL FACTS, WHICH SERVED AS A |BASIS FOR ISSUANCE OF ‘HIS PERMIT,. REQUIRE JHE APPLICANT TO MODIFY THR PERMIT APPLICATION. ISSUANCE OF THTS PERMIT DORS ‘STATE, OR LOCAL manson REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SUCH MODIFICATIONS MAY -RESULT IN THIS - PERMIT BEING MADE NULL AND VOID. NOT EXEMPT. THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, “ie SYSTEM DESIGN AND SPECIFICATIONS FILL REQUIRED: Cc 9 TL 750} Gartmons |/ cep Seotic CAPACITY AL 01 cannons |/ cpp CAPACITY . NI 0 ] GALLONS apense INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALEONS] K[ _] GALLONS DOSING TANK CAPACITY i” IGALLONS. @[ ]DOSES PER 24 HRS #Pumps [ 1 Dt 360 } SQUARE raf 120 linear Ft PTI MPS-11_ sysT=m RL. 0 } sQuarz, = : SYSTEM A TYPE SYSTEM: i 1] STANDARD { ] FILLED [ ]- MOUND ti] I CONFIGURATION: f |) TRENCH ‘{¢] BED aml N ¥ LOCATION OF BENCHMARH: Orange. Dot C/L Lion Ter, Left Pl. 50:00 (ass'd) . I ELEVATION oF PROPOSED) SYSTEM STTE t 6.00 i darsae} Fr 11 ABOVE git sma eerenme POINT E ROTTOM OF DRAINFIELD [TO BE C d#o0 1 (rxcnes] lilixcres) rr 1¢ apoveAaerow]BENcMark/RErERENCE POINT L D 60] INCHES EXCAVATION REQUIRED: [ 60,08] INCHES a The licensed contractor in: 8, 64E+6,013(3)(f), FAC. R Install a new sratera to Remove existing drainfiel a H SPECIFICATIONS BY; YY, DATE ISSUED: DH 4016, Pe 10/97 (Previous Editions May Be Used) falling the system i is tesponsible for installing the. minimum category of tank in accordance with quired drainfield area based on rule 64E-6, 015(8)(¢)2. chieve Drainfield size requirement. material and associated spoils to 60" below grade. Replace with appropriate drainfield material. VITLE: Environmental Supervisor Charlotte CHD EXPIRATION DATE: 10/25/2009 Page 1 of 3 vilii.a APYI0A20 SE793144 ATTACHMENTB PERMIT NO. _———_—— pATS PAID. _—____—~ STATE OF BOE HE TH oe FEE PAID: DEPARTMEN oF HEAL , ———— ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM RECEIPT #2 CONSTRUCTION PERMIT ee ‘CONSTRUCTION PERMIT FOR: , vative { ] New System { J Existing System t 3 Holding Tank | i Inn (Al Repair { Abandonment [ ] Temporary EEE APPLICANT: ANORGA Tecan TRUSTEE AMEERE 4FROPERTY ADDRESS: 20282 Aeguer dR, Por. LA Lor7e AL SSIS Por S&C. 18 : OT: 6 . Fb 4 ___susprvisioN: OT: BLOCH: [TSECTION, TOWNSHIP, RANGE, PARCEL NUMBER] ‘pROPERTY ID #: GORRIOIE G00 | | [OR TAX ID NUMBER] 15-40-22 a R SYSTEM MUST BE CONSTRUC) iD: @.8., AND CHAPTER 6AE-4@, F.A.C. DEPARTMENT ‘PERFORMANCE FOR ANY SP. CIFIC PERIOD OF TIME. BASIS FOR ISSUANCE or | THIS PERMIT, REQUIRE THE APPLICANT Oo MODLEY T BUCH MODIFICATIONS MAY RESULT IN THIS PERMI iC DOES NOT EXEMPT THE Al PLICANT FROM COMPLIANCE REQUIRED FOR DEVELOPMENT OF THIS PROPERTY . ‘SYSTEM DESIGN AND SPEC{FICATIONS wv [7SO | GALLONS / GPD_SEPTIC TANK |ULTI~CHAMBERED /IN-SERTES [A] . aT ] GALLONS / GPD CAPACITY MOULTI~CHAMBERED/IN-SERIES [ woe ] GALLONS GREASE INTERCEPTOR CAPACITY {MAXIMUM CAPACISY SINGLE TANK: 1250 GALLONS” gt } GALLONS. DOSING TANK CAPACITY [ |] GALLONS @ [ } DOSES PER 94 HRS # PUMPS [ [360] SQUARE FEET) REPLACEMENT DRAINFIELD system /ZO Zivene Kr, P22 mb$ 0} Ehuvat io ] SQUARE FEET SYSTEM . : TYPE SYSTEM: {| STANDARD { ] FILLED [> | MOUND f 4] CONFIGURATION: [ | ]} TRENCH [A] BED ct] ELEVATION OF PRO D S¥STEM SITE [ 6” ] [INCHES/FT) [ABOVE/BELOW] BENCHMARK, [REFERENCE POIN LOCATION OF “crore OCRence 807 7 Z10N 7ERR eer? Ale (S06 a0’ Aeumee) POS: : BOTTOM OF DRAINFIELD TO BE t /%@" 1] LENCHES/FT! [ABOVE /BELOW] BENCHMARK/REFERENCE POIN OM briny BZ be abt FILL REQUIRED: [ W/A ] INCHES EXCAVATION REQUIRED: [60 ¥ 7 INCHES © Remove EGASPIVG ORAINAGCYO MAIER IAAL A A. a? Vd : f 3 : NO APAOCS GO SAt/o$ 7o 40” (hte ek) GGern Gks a F oy) , )_ 46 O6 . FRE Cet CG WTA] APP REPEIA 7E ORAINEAIECO ~ 3 U., te Ba SPECIFICATIONS BY: TITLE: ConvrRAe 7OR. APPROVED BY: TITLE: CharlotteCHD SATE ISSUED: : ; EXPIRATION DATE: DH 40 i Lor 16, 10/97 (Previous Editions May Be Used) Page 1 of 3 DEPAR' |} ONSITE SYSTEM APPLICATION FOR: STATE OF FLORIDA APPLICATION FOR. CONSTRUCTION PERMIT WAGE TREATMENT AND DISPOSAL T OF HEALTH permit No. O94 - - DATE PAID: 9- 4- 3-07 FEE PAID: 255 Ao RECEIPT #: Lee { ] New System [/.] Bxisting System : { J Holding Tank [ ] Innovative {X] Repair (| 1. Abandonment { 1]. Temporary APPLICANT: Aner GCA Veécemanl - TRUSTEE Lok Zeora 1 ot. ie) ecensss) AGENT: Sar tral| SEP we ve ERVICES TELEPHONE : 4297 $842. MAILING appREss: 2 S08" Teo Prenrec btvb, Waser TO BE COMPLETED BY BY A PERSON LICENSED coe APPLICANT’ § RESPONSIBI PLATTED (MM/DD/YY) IF Sesaossse Sse Sse PROPERTY INFORMATION ot: G PROPERTY ID #: 402 BLOCK: GE & - 16/8 2.001 LH SUBDIVISION: Sée. end eae ae cence eeeee seen As SYSTEMS MUST BE CONSTRUCTED If IS THE PLATTED: PROPERTY StzE: 0°24 18 SEWER AVAILABLE AS PROPERTY ADDRESS: ACRES WATER SUPPLY: PER 381.0065, Fs? [ ¥ /@1 t DIRECTIONS TO PROPERTY: SEée mAP ATTACHED ZONING: ASE S ] PRIVATE PUBLIC [%]<=2000GPD [ -$_ I/M OR EQUIVALENT: [ ¥ (GL) j>2000GPD DISTANCE TO SEWER: (V/M__ Pr 2obee Acsuar dr, Foer CHpays77é, KL 33952 BUILDING INFORMATION Unit [%] RESIDENTIAL { ] COMMERCIAL Type of No. of Building Gommerdial/Institutional System Design No Establishment [| Bedrooms Area Sqft Table ll, Chapter 64E-6, FAC 1 . SAR a 1,36) V/A a 2 3 —_ _ 4 ~ ~ _ tJ Floor/Equipment Drains { ] Other (Specify) oo| 0 SIGNATURE: DATE: We. 3 3/0 09 ae f af, & DH 4015, 10/97 (Previous Edi i1ohS May Be Used # Y Page 1 of 4 0999 bb ~ Wis-80 DEPARTMEN ONSITE SE SITE EVAL apesreas: Avoren Terman - Teus7ee _ STATE OF HLORIDA OF HEALTH AGE TREATMENT AND DISPOSAL ‘SYS ATION AND: SYSTEM SPECIFICATION PERMIT #. i AGENT: JURR ro Serre JSCRVICE. & siock: $6 “LOT: suspivtston: PCA SEC. 4 7& PROPERTY ID #: 4OAR/E/E ZOO! 46-40 TO BE COMPLETED BY ENGINE) MUST PROVIDE REGISTRATIO) R, HEALTH DEPARTEMENT EMPLOYEE,OR O NUMBER AND SIGN AND SEAL EACH PAGE PROPERTY SIZE CONFORMS TO SITE PLAN: v3 YES { ] NO NET US: TOTAL ESTIMATED SEWAGE FLOW: AUTHORIZED SEWAGE FLOW: UNOBSTRUCTED AREA AVAILABLE: /000 LOCATION: DRANGE G07 Ge, S10 VORR. LGET A/t. (§0'o0 BENCHMARK/REFERENCE POINT #LEVATION OF PROPOSED SYS THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SURFACE WATER: W/, ET WELLS: PUBLIC: AW/A ET BUILD ENG FOUNDATIONS: SITE SUBJECT TO FREQUENT ‘10 YEAR FLOOD ELEVATION HOR SITE: - ‘ SOIL PROFILE INFORMATION sire 1 S0O-So." GALLONS PER DAY [ GALLONS PER DAY [ SQFT UNOBSTRUCT! Z00 | 600 [Section/Township/Parcel No. or Tax ID Number] HER QUALIFIED PERSON. ENGINNEERS F SUBMITTAL. COMPLETE ALL ITEMS. LE ARBA AVALLABLE: 0°22} aAcRES SIDENCES-TABLE 1/OTHER-TABLE2]} 500. GPD/ACRE OR_2500 GPD/ACRE 1D AREA REQUIRED: 700 SQFT ITEM SITE IS 4% LINCHES/FT] [ABOVE DITCHES/SWALES: 58’ FT LIMITED USE: W/# FT PRIVATE: , FT PROPERTY Lines: 4z’ FLOODING: [ ] YES q 0/4 SITE ELEVATION: , BELOW] BENCHMARK/ REFERENCE 2) SYSTEM TO THE FOLLOWING FEATURES. NORMALLY WET? [.] YES Lory a”, Fr NON=POTABLE : mie’ : MA POTABLE WATER LINES: 2S 7 Fv L] Yes {] wo FT MSL/NGVD © YEAR FLOODING? oO, SOIL PROFI | INFORMATION srtE 2 SO: 407 . | MUNSELL #/COLOR TEXTURE DEPTH [ MONSELL #/dOLOR TEXTURE DEPTH | f ah ‘ OF TOO" Khe : #38 ov TOR” d Ww Geayeuy FS 9 to 48" FS 0 Gravare. &" Tye ve G/T Gre Fé is" 00 265 3 ge go | ff te" TO Bar #S 2a” TO Jey Ge Ye Lone eer 32” TO 36” RE (17a Ys Cmepsr 32" TO 34” 7 a4" TO 42" zs SE" 10 g2” por Ws ta Sanoe bee. 42% TO SO” Pawsod ee Y TO Mer" 5; rao wank “og? 20 — ro TO | USDA SOTL SERIES WOR PP EO BS ASS Deasmar Saevd USDA SOIL |SERLES: Arapred _¢~s # oF OL ai mie ; s - Sav! QBSERVED WATER TABLE: INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT ESTIMATED WET SEASON HIGH WATER TABLE VEGETATI SOIL TEXTURE/LOADING RATH DRAINFIELD CONFIGURATION: ae " WATHR TABLE ELEVATION: ON: [ ] YES {[X] NO vor system sizinc: Ad /O'8S pv [ ] TRENCH : [A] BED { ] OTHER so w pra of Excavariont 60 32" INCHES (ABOVE / BELOW] BRILSTING GRADE ; MOTTLING: ¥] YES [ J] NO DEPTH: &2” INCHES INCHES (SPECIFY) vtties) Setan Ceade on FREE ORMMING SAM REMBRKS/ ETT ONAL CRITERIA: *O/Gion? 70 £6°% ASK) mugen ie| Keg7an &8 | 0636LV6O @_ 32" BL" bGtrw/ GRAIG | { SITE EVALUATED BY: A darn Renolelem p K BA (07k Ye etude Comms POUSIMET bh 4015, 10/96 (Replaces HRS-H [ Form 4015 [page at which may be used) | | EAS, CEA vate: [23/09 Page 3 of 4 { . | STATE OF FLORIDA t | PERMIT # DEPARTMENT |OF HEALTH : ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM EXISTING SYSTEM AND SYSTEM REPAIR BVALUATION APRLICNNT: ANOREA (éemane Rus 7OG CONTRACTOR / AGENT: VET 7rrv LEA a AC. J CRVICE Lor: _&@ BLOCK: whe SUBDIV: Pen SEC. 8 ___ WH ORR/ELE 18300} @O BE COMPLETED BY FLORIDA REGISTERED. ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS . MPLETE TANK CERTIFICATION BELOW OR ATTACH LETTER FROM A PERM TTED SEPTAGE DISPOSAL SERVICE. TANK INFORMATION - 1780 ] GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERTAL CONGRGE 7G BAFFLED: [x /GQD “7 GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL: __ BAFFLED: [¥ / NJ i ] GALLONS GREASE I[WTERCEPTOR GALLONS DOSING F OTED TANKS WERE PUMPED ON 06 /2&% /O% , HAVE THE VOLUMES SPECIFIED, ARE RAVE, A KS DE! TON DEVICED 7 QULLET FILTER DEVICE 1 STALLED . ase, ONC jACAVICE PRE /OF CENSED CONPRACTOR s0Sniess NAME TE EXISTING DRAINFIELD “ee i ' £/60. ] SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ]. DIMENSIONS: S ’ x 0” i ] SQUARE FEET _ 7 |\_SYSTBM NO. OF TRENCHES [ ] DIMENSIONS: xX TYPE OF SYSTEM: [ ] STANDARD [ FILLED [7%] MOUND [. ] QONFIGURATION: [#4] TRENCH t ‘BED C ] DESIGN: [ ] HEADER [794] D-BOxX [A] GRAVITY S¥s [ ] DOSED SYSTEM | SLEVATION OF BOTTOM OF DRAINFIELD IW RELATION TO EXISTING GRADE 28 “INCHES [ ABOVE / BELOW] SYSTEM FAILURE AND REPAIR TNFORMATION £/970 | S¥STEM INSTALLATION DATE : . TYPE OF WASTE [ 41 pomesTrc f ] COMMERCIAL ‘ 260 °] GPD ESTIMATED SEWAGE FLOW BASED ow [%] METERED WATER [ ] TABLE 1, 64-6, FAC SITE [ ] DRAINAGE] STRUCTURES tl ] POOL [ ] PATIO |/ DECK [ ] PARKING ZONDITIONS: [%-] SLOPING PROPERTY ( ] : : ! NATURE OF [ ] HYDRAULIC) OVERLOAD { ] SOILS [ ] MAINTENANCE [ ] SYSTEM DAMAGE FAILURE: [ ] DRAINAGE / RUN OFF { 1] Roots [ ] WATER /fABLE (%1 AGE = i . : . SAILURE { ] SEWAGE OW| GROUND {| ] TANK [A] D BOX/HEADER [x] DRAINFIELD SYMPTOM: {% ] PLUMBING BACKUP | 2a SSMARKS /ADDITIONAL cRTTERfA i | ne ee | L i f SUBMITTED BY: } 8 1 aR 7) A. G KB i . -——_--— i i amas /uxcENse Lau coa/ Con RAC 70K DATE: zpos) 9 | ATTACHMENT R41 ‘STATE OF FLORIDA DEPARTMENT OF HEALTH ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUCTION AND.INSTALLATION PERMIT SHOW THE FOLLOWING: i Existing system configuration and location, building location, property slope (if any) “rights-of-way,” ob: systems, surface w ce PERMIT NUMBER _ PART Ih = SITE PLAN osecsefecsssecsssessssetseseersssoisnsstinstinnn FOR REPAIRS & HOLDING TANKS ONLY , property lines, easements, tructions (buildings, driveways, sidewalks, etc.) private and public wells within 100° of ter and stormwater retention systemp, and repair system: configuratign. : — O44AU Pr : 932) H 307 * W- ame 4 GG RA No LURFACE wh 7eR_ £o0y ies es 7 ¥ POPARL Ge Maren 6A 20814 20nj OD wv ; ‘ Ste Mt COCA PE beter pe ws? OR PRepezz “2 la peorearee ANE) CACEPZ fj ORAIVING 1107 72 SCALE iefly describe the nature of the failure: MEV G EK UA Cul 7D |SCOW) ORMINING ERA EIGED Site Plan submitted by: 7 ; Y Gh tn LAr] Weieyn REAS, CENIF , : Title Pian Approved __| By County Health| Department Signature Not Approved Date ALL CHANGES MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT . ONSITE SE STATE OF FLORIDA DEPARTMENT OF HEALT WAGE DISPOSAL SYSTEM CONSTRUCTION A PERMIT NUMBER PART Il - SITE PLAN SHOW THE FOLLOWING: Existing system configuration and location, building location, property sk “rights-of-way,” obstructions (buildings, driveways, sidewalks, etc.) systems, surface water and stormwater retention ’systemb, and repair s| pri aw CeeU PA D INSTALLATION PERMIT FOR REPAIRS & HOLDING TANKS ONLY pe (ifany), property lines, easements, vate and public wells within 100' of stem configura Qh, Re raage . @ bn fl h(a RE Ee é - ¥ ; . WE DLAINEI Gt oe $ Gnred % 20 / PID p08 1) FB 120 Liven. P32? e307 Fr. * in same devene. PREM OF EYE, foc@ SY 87am) a“, A . nS s } Line = pe & 7 WwheArthay & © 2ce| ra Hed Fae a aa “CXS ATS pow EE aN © [NE SORFACE WATER gpg S| ®© PLIABLE WATER BR zp eigen OS . ete PS Con FEd trey, = OK PROPCATY ve, Exceey f AA poreaTen Ly - — AC Bury OR. _ ORANGE 7107 72 SCALE & 7O slew GRADING Title Site Plan submitted by: 7 / “a ton CRY] Ge erh REAS, CEASE Plan Approved ____ | By County Health D ALL CHANGE . Signature Not Approved partment Date MUST BE APPROVED BY THE COUNTY HEALTH DEPARTMENT ) K) aS ‘PROPOSED . ELEVATION 49-90’ 4% 7G? 99-50’ ‘So. 22! 49: 60" 48-85) SO -SO or: rey $783" 0-667 . . E.S.H.W.T. SEPARATION /2°/ Jn. ESHW.T. a c. Q. R. BENCHMARK LOCATION ORGeGE- Op? Leer rene. err h/t BENCHMARK ELEVATION __© 9 ‘00 /gvtumeo) LIFT STATION? Yes X No! 07/23/200 : : o ; : TAPERS ON: 55 FAL { 001/001 listoryAWeather Query a (CCU yo 4-MAR-2009 os Fea 200s _fOSUAN 2009 Is. Dec-2068 jo4-Nov-2008 ent tyre teenie 4 yw of al 9 " Charlie Crist Governor NonFeaTion TO SUPPLY ADDITIONAL INFORMATION Ana M. Viamonte Ros, M._D., M.P.H. State Surgeon General {Applicant [ 7??? Permit # 09-365RP | Address [TRUSI¢e on Property App. | Property - 20282 Albury Dr ; does Not makeh Apolican’| Address Fax# 941-429-1602 fax ‘Septic Contr. | |.Martin Septic Service The application for} for the following re can be processed 64E-6.015 Perm (a) A site plan s co earation ave potable water lines, within the existing and proposed drainf slope of the prope any surface waterbodies and stormwater or public wells, o 2 septic system construction permit for the a iting and Construction of Repairs location on the property, the building loc rty, property lines and easements, any 0 onsite sewage system which, restricts replacement or relo The existing drai minetal aggregat - site plan: Slope of Property, Indicate were existing system field type: shall be described, For exampl , chambers. or other. Information missing drainfield to the structure, son(s): Your application needs to provide th owing property dimensions, the existing a ove site cannot be processed following information before it d proposed system ion, potable and non- eld repair area, the general structed areas, any private — systems in proximity to the tion of the drainfield system. , mineral aggregate, non- that must be indicated on is located, distance from 64E-6.Please verify the irrigation. well will be 55° to: new drainfied, 64E-6.015 Perm A permit shall be| the submission of an application accompan Form DH 4015, 1 itting and Construction of Repairs issued on Form DH 4016, hereby incorp ied by the nece 0/96, hereby incorporated by reference, s ated by reférence, only after sary exhibits and fees. all. be used for this purpose, and can be obtained from the department. Need plotted date on-application. home and my pr make sure you a it was requested Leslie Beauchary Environmental S The application shows that a lift station will not be necessa permits. We agréed to do so with the 115.00 site evaluatio to verify please submit the 115.00 and we will gladly perfor avoid any mishap’s fessional experience and knowledge | as that we go and perform a site evaluation p . upervisor Date: July 24, 2009 . Based on the age of the that you review this to e certain it will not be needed. Per conversation with Marty and Cindy rior to, our issuing the fee paid. If you wish for us ma site evaluation now to This information must be supplied to this office on or before 8/24/2009 Charlotte County Health Department « Environmenal Health 18500 Murdock Circle, Rm 203 » Port Charlotte, FL 3 3948-1094 Tel. (941) 743-1266 « Fax (941) 743-1533 Charlie Crist Ana M. Viamonte Ros, M.D., M.P.H. Govemor State Surgeon General ATTACHMENT A . EXISTING SYSTEM/MODTTCATON ae INSTRUCTIONS FOR COMPLETING AND SUBMITTING YOUR SEPTIC PERMIT APPLICATION i. You will need to have ALL tanks pumped by a permitted septage disposal service to determine the yolume and structural integrity of the tank. volume must be determined by the actual inside dimensions of the tank, and this informat n must be included on the certification ( application.. If Y you have the proper paperwork, you don’t have to have the: pumped again 2. Site information sheet and application filled out completely] signed and-dated. 3. Site plan — This is the most important part of your applicatian, please take the time to — ensuré you have all features accurately depicted. The site plan (signed and dated) must show exactly what you propose to do on the site. See below Draw the location, and show dimensions of lot boundaries. Youlmust show building location, potable and non-potable waterline, any easements, roads, obstructions, wells (on said, and all adjacent ptoperties), surface water, driveways, walkways, the lo pation of both existing and proposed tank(s), and drainfield. In addition to the location, indicate the estirnated distance to all said features. Yjou must show location of any private utilities have been installed on the property such as electrical lines, sprinkler lines, etc. The CCHD jis not responsible for damage to private property; underground utilities must be indicated to. the: CCHD so we can take action to-avoid thém. This is a Safety concern as well as possible interruption of service. FOR EXISTING OR MODIFICATION PERMITS 4. Floor plan ~ Attach a copy of both the existing, and proposed floor plan for your house, Mobile or Manufactured home, or business. 5. Permit Fees: Existing system application $180.00 (Repair system application $360.00, CCHD site evaluation 525.00 Modification without tank replacement system application $380.00 Modification with tank replacement system application $430.00 (Modifications with CCHD performing site+ existing evaluatjon add 165.00) APPLICATION PACKAGES WILL BE CHECKED FOR ACCURACY PRIOR TO ACCEPTANCE, INCOMPLETE APFLICATIONS CANNOT BE ACCEPTED, I have tead the above and understand the aforementiqned regulations. Charlotte County Health Department * Environmental 18500 Murdock Circle, Rr 203 » Port Charlotte, FL. 339 : Tel. (941) 743-1266 * Fax (941) 743-1533 ATTACHMENT RR? Charlie Crist Governor Ana M. Viamonte Ros,.M.D., M.P.H. State Surgeon General NOTICE TO APPLICANT Because of the requirements of chapter 556, Florida Statutes, Underground Facility Damage Prevention and Safety Act, it is mandatory that this office apply for for your property prioy days, and up to five days to receive a locate ‘ticket and if any o' ticket request is incorrect or missing, it will take longer. We realize There itis a necessary aid in preventing permitting process. it to your permit.appii to performing any site work on your prop erefore, it is imperative that we have your tand this notice, please date and sign the bo} ation. : and receive a utility locate ittakes a minimum of 2 required information on the his will slow down the ssistance in this process. s to your property, this anything that might prevent I large deg. To ensure you tom of this page and attach — injury, and potential Please note that private utilities are not located: during this process, Any electrical lines installed under groun on the site plan any u: Health Department is of our evaluation or in SLM Revised 6/6/07 bi A. Gugrer , Sprinkler lines, etc wilt not-be marked by thi tities youor previous owners may haveit pection process. 28/69 Kastan is process. Please indicate led. The Charlotte County stall 1ot responsible for damage caused to orivatd property during the course D/OSTDS2007 : Charlotte County Health Department « Environmental Hath 18500 Murdock Circle, Rm 203 « Port Charlotte, FL 13948-1094 Tel; (941) 743-1266 « Fax (941) 743-1533 Charlie Crist Ana M. Viamonte Ros, M.D., M.P.H. Governor _ State Surgeon General ; PROPOSED SITE INFORMATION YorN a " y 1. [ls there any slope to your lot? : Slope is the percentage of fall in a specified diane. If the property is flat, it bas no slope. If the property has slope, indidate the direction with arrows. : N Y 3. N . 4. e there any existing or proposed wells on ease indicate use, irrigation or drinking) pt yout lot? Ef'so, you must have the “1 2. Are there any public wells within 200 feet of your lot? t within 75 feet of your lot? Are there any lakes, streams, canals, or stance water, anor within 75 feet ual flood line” determined y this office.or a certified professional surv surveyor and mapper with experieneé:in the determination-of flood waterlelévation ines. If you wish ¥ have this office determine, initial here |__. (Chapter $1.0065(4)(i). Florida Statutes) a 5. Are there any easements on your property? Y 6. Are there any drainage features (i.c. ditches, swales, drainage retention areas, storm water piping, ot interceptor drains, etc.) on, or within 75 feet . ‘of your lot? N 7, Are there any underground utilities located on your property such as sprinkler lines or electrical lines? Name: Clgye aid Seen, S ERYICE Title: ; Say Fie. Con IR e700 owner, building contractor, septic contractor, other) — Date: Vere Y AS 09 Ifyou marked /*Y¥” next to any of the above questions, please draw and locate on your site plan{s). tevised 607 1/2/2007 . KASHAREDNOSTDS2007 Charlotte County Health Department « Environmental. Health Tel, (981) 743-1266 » Fax (941) 743-1533 18500 Murdock Circle, Rm 203 « Port Chartatte, FL 33948, 1094 STATE O 2 ~=DEPAR' | ONSITE SITE E APPLICANT: CONTRACTOR / nor: 6 SUBDIVISION: Pp APPLICATION # AP930420 PERMIT # 08-SM-996650 DOCUMENT # SE793473 FLORIDA NT OF HEALTH EWAGE TREATMENT AND DISPOSAL SYSTEM — UATION AND SYSTEM SPECIFICATION . Andrea Telman, {Tr . “ AGENT: Martin Septic : BLOCK: 464 ID#: 402216184001 C Sec 18 TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. REGISTRATION. NUMBER AND SIG ENGINEERS. MUST -PROVIDE AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS, RET USABLE AREA AVAILABLE: PROPERTY SIZE CONFORMS ‘70 SITE PLAN: [X]YES {[ ]No 0.24 ACRES TOTAL ESTIMATED SEWAGE PLOW: 300 GALLONS PER DAY ( [nagipences-samnea]/ OTHER-TABLE 2 ] AUTHORIZED SEWAGE FLOW: 599.98 GALLONS PER DAY [ 1500 GPD/ACRE OR [2800 epp/acez_|}) UNOBSTRUCTED AREA AVAILABLE: 4200.00 SQFT UNOBSTRUCTED! ‘AREA REQUIRED: 800,00 sort BENCHMARK/REFERENCE POINT) LOCATION: Orange dot cl:lion ter, left pl 60.0 (ass'd TEM SITE 0.32 [ INCHES / [ee | t[anove |7 BELOW. ] BENCHMARK/REFERENCE POINT ELEVATION OF PROPOSED SYS! THE MINIMUM SETBACK WHICH SURFACE WATER: : WELLS: PUBLIC: BUILDING FOUNDATIONS: SITE SUBJECT: TO FREQUENT hrocpiné? 10 YEAR FLOOD ELEVATION FF SOIL, PROFILE INFORMATION USDA SOIL SERIES:Oldsmar a: Munsell-#/Color 10YR 4/3 10YR 6/1 10YR 7/6 4OYR 4/4 10¥R 5/6 REFUSAI Gi OBSERVED WATER TABLE: ESTIMATED WET SEASON WATER HIGH WATER TABLE VEGETATION: SOIL TEXTURE /LOADING RATE FOR SYSTEM SIZING: DRAINFIELD CONFIGURATION: REMARKS/ADDITIONAL CRI 10YR 7/6 mottling found at 24" in 4 SITs EVALUATED BY: DH 4015, 09/2006 (Previa lay Lowi : To Oalitic Limestone 4 “ CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING ‘FEATURES i DITCHES/SWAIES: 55 Fr NORMALLY WET: [ ]¥ES [X]NO ud LIMITED USE: FT PRIVATE: FD NON-POTABLE: ¥T 5 FI PROPERTY LINES: 40 Fr POTABLE WATER LINES: 1.4 FT t iBs [x ]NO | 410 YEAR FLOODING? [ ]¥ES [XINO, DR SITE: FR MSL / NGVD] SITE ELgvavion: SO .3% FT t waar gioe SOLL PROFILE INVORMATION SITE 2 : USDA SOIL SERIES:Oldsmar sand | Munsell #iGofor___Textute 1OYR:413: i Fill - Firie-Sand 1OYR'6M Fine Sand TOYR 7/6 ; EMNIDST RE | 10YR 4/4, : _ Fine'Sand’ 4OYR 56° Clay.Laam REFUSAL Qolitic:Liméstone ¢ oar INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE: { PERCHED / APPARENT J faBLE ELEVATION: 24 INCHES ABOVE / EXISTING GRADE { lyzgs [xk]No MOTTLING: [X]YES [ ]NO DEPTH: 24,00: INCHES Fine Sand/0.60 ‘(DEPTH OF BXCAVATION: INCHES { ] TRENCH ILTERIA (X] BED [ ] OTHER (SPECIFY) OYR 6/1 matrix common and distictive J : i 07/30/2009 filson, Shawn (Title: Environmental Specialist Il) (Charlotte County Environmental He . ss Editions May Be Used) Page 3 of 4 AP930420 EIDS96650 v1.02 f i SEPTIC SYSTEM ELEVATION WORKSHEET PERMIT ELEVATION CALCULATIONS: USE 100.00 OR 10.00 ASSUMED FOR REFERRENCE POINT/BENCH MARK LOCATION OF BM ofane e aot cl vd ale PD pm= 9 9-0 SHOT (+) yy. aa HEIGHT OF INSTRUMENT= (HL) Ht. 52. EXISTING ELEVATIONS: . GROUND AT TOP OF TOP OF . BOTTOM OF TOP OF TANK TOP OF TANK SOIL PROFILE OF COVER DF STONE DF STONE OUTLET INLET Hil. = BY SH = Hd. = HA. = His $4.52 H..= «sHoT _ 4.30 (SHOT) SHOT _ (-}SHOT | (-)SHOT _$./@ (-) SHOT “ELEVATION. |_&O «32, ELEVATICN ELEVATION ELEVATION ELEVATION 49,42 ELEVATION PROPOSED DRAINFIELD ELE’ ‘ATION CALCULATIONS _ ae ELD SIZING. ERIOR TO 4983 EXISTING DRAINFIELE EXISTING GROUND = 50-BR, DEPTH TO SHWT (-) A REPAIRS PER COUNTY W4, ; 2 ORDINANCE 4.00:FT SHWT ELEVATION 32 7 MODIFICATION 4.00 FT OR . #REQUIRED SEPARTION (+) I AT EXISTING ELEVATION . _ IF HIGHER THAN 1.00FT ; FOR DRAINFIELD SIZING ELEVATION BOTTOM Y9 Br oR —e OF DRAINFIELD 2.00 SEPARATION IF EXISING . LESS THAN. 1.00 - TOP OF EXISTING emery . \ TANK OUTLET PIPE 1S APUMP REQUIRED? YES OR NO -0.83 EQUALS 78. 59 NEW ELEVATION OF ORAINFIELD MUST BE LOWER OR A PUMP WILL BE REQUIRED EXISTING ELEVATIONS: NEW ELEVATIONS: TOP OF BED BOTTOM OF BED RAISE FIELD BOTTOM INCHES SOIL COVER OVER BED RAISE YARD ELEVATION INCHES SHWT SEPARATION | SHWT.SEPARATION INCHES EXISTING TANK GALLON GALTANK NEW IF REQUIRED Discharge hours are 24 hour days ‘a week, All information requested on this and any other form, must, be. complete and accurate without exception. Iti is very important when ‘the grease switeh is ON. and you! have completed unloading that you éirn your key OFF . and get areceipt before turning the switch back to RE P REGULAR, COMPOSITE ATTACHMENT c ett OWAAITRR 0. ey PINKS weal DEPT: “9a3/03-- an fae? yery important when the grease switch is ON a: ee DEES ot and get a receipt before turning the witch back to x ne yo! u eted unloading, that yc u turn your: * PINK-HEALTH DEPT... in up after a A omplete and a curate without exception. Atis, ‘important when the grease switch is, “and get a receipt before turning the switch back to e¢ completed nloading that you tu your key OFF: ane y OO Aire ATT Discharge hours’ re 24h mplete ‘and accurate without exception, 3. All information requested on this and any other form your key OF ¥F t ‘very important when the g ‘ease switch is ON and-you have com receipt before turning the switch back to REGULAR...” * 0313/08 WHITE-CCU : 6 + “YELLOW-HAULER |: 03/13/03 urs are 24 hours/7 days aw Discharge ho lete and accurate without exception. All information requested on this and any other form must be comp “4, ‘It is. very important when the grease switch is-ON and you have ct ( d you ha .p! sted unloading hat you turn your key OFF ‘and get a-receipt before turning the switch-back to REGULAR. fo Teerign ie Ais ea ce, - WHITE-CCU aa “: : YELLOW-HAULER : - : - PINK-HEALTH DEPT. . “033/04 : io @ cn, 7 07 420K? . PERMIT #: 08-SM-16395 APPLICATION #: AP935301__— STATE OF FLORIDA DEPARTMENT OF HEALTH DATE PAID! / ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: SYSTEM RECEIPT #: TUGrH AT ALSO pocument #:PR784282 Abn N bye ostps #: 06-083 06-0831-N CONSTRUCTION PERMIT FOR: OSTDS Repair ve. LEXL APPLICANT: Vitaliy Kiktenko PROPERTY ADDRESS: 9320 AnitaAve Englewood, FL 34224 a Lor: 15 BLOCK: 3467 SUBDIVISION: PC Sec 74 PROPERTY ID #: eae [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] + 20648200015007 [OR TAX ID NUMBER] eee 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. RNY 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 NOLL AND VOID. ISSUANCE OF THIS PERMTT DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY. SYSTEM DESIGN AND SPECIFICATIONS tl 600 ] GALLONS / GPD Existing Aerobic Unit CAPACITY AT 0] GALLONS / GED CAPACITY Ni 0 ] GALLONS GREASE INTERCEPTOR CAPACITY [MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS] KI ] GALLONS DOSING TANK CAPACITY i ]GALLONS §@[ ]DOSES PER 24 ARS #Pumps [ J DE 700 ] SQUARE FEET Replacement Drainfield _ S¥STEM RT C ] SQUARE FEET SYSTEM A TYPE SYSTEM: { ] STANDARD { ] FILLED [x] MOUND tJ I CONFIGURATION: { ] TRENCH [X] BED tl N ¥F LOCATION OF BENCHMARK: orange dot cl alley right pl 50:0 (ass’d) I ELEVATION OF PROPOSED SYSTEM SITE (41.30) Lancuss| Fr 1 tlapove}) sELOw }BENCHMARK/REFERENCE POINT E BOTTOM OF DRAINFIELD TO BE - ¢ 18.60) {rscuss) rr 1 anova) BELOW JBENCHMARK/REFERENCE POINT L : D FILL REQUIRED: { 0.00] INCHES EXCAVATION REQUIRED: [ 24.00] INCHES Remove existing drainfield material and associated spoils to 30" below grade within the drainfield area. ° Using 233 linear feet of PTI-11 or equivalent B R SPECIFICATIONS BY: Martin A Guffey TITLE: Septic contractor APPROVED BY: Ayan £ Wr TITLE: Environmental Specialist II Charlotte cH Shawn EB Wilson : DATE ISSUED: 09/08/2009 EXPIRATION DATE: 12/07/2009 DH 4016, 10/97 (Previous Editions May Be Used) Page 1 of 3 void APS25301 SEMGLIC 26/ FS ATTACHMENT D , a e o ae i STATE OF FLORIDA PERMIT NO, 09-4 30KP DEPARTMENT OF HEALTH . DATE PAID: 9-9 oF ONSITE SEWAGE TREATMENT AND DISPOSAL FEE PAID: 36707 SYSTEM RECEIPT #: 9. og o¢ APPLICATION FOR CONSTRUCTION PERMIT Li BOVIS APPLICATION FOR: C J] New System { ] Existing System { ] Holding Tank { ] Innovative [X] Repair [ ] Abandonment { ] Temporary apprrcant: _V/7A2) yy RIK TENKO AGENT : Vdeies “iad SEP FC Vex vil & TELEPHONE: 427 ~ £84 2 MAILING ADDRESS: 2.508 Ten Picnree Ezy Te SSSR SS SS SS 2 TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS MUST BE CONSTRUCTED BY A PERSON LICENSED PURSUANT TO 489.105 (3} (m) OR 489.552, FLORIDA STATUTES. If IS THE APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR PLATTED (MM/DD/ Tx) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS. PROPERTY INFORMATION ot: 7S snock: $467 suaprvistoen: SCA Sec 74 puarrep: 7/6/60 PROPERTY Ip #: F/Z0023770// ZONING: A 774/O r/M OR EQUIVALENT: [ ¥ /@> PROPERTY Size: 0°2 7 ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [ x]<=2000epD { ]>2000@PD 7S SEWER AVAILABLE AS PER 381.0065, FS? [ ¥ (®)] DISTANCE TO SEWER: “V//} yp PROPERTY apprEss: F320 /Sws74 Ave, Enaceossoo FL S¢22g DIRECTIONS 70 property: VEE yyw ATT AK ED BUILDING INFORMATION {>%] RESIDENTIAL I 1 commercrar Unit Type of No. of Building Commercial/Institutional System Design No Establishment ‘Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC = See shment —S———=e L M1471- KAM, RES 4 2266 W/A 2 ata 3 4 { ] Floor/Equipment Drains ] Ofher (Specify) SIGNATURE: DATE: G/ 8/09 FLV A . Gukkey DH 4015, 10/97 (Previous Editions May Be Used) Page 1 of 4 9.24 ia 4 t ALIS: DRAINFIELD New ORANFAIGCO (RESIDENCE) +F ELEVATION = 53.34" § Ganed %30'P7TZ mest F: ( = 240 Lineac Fr. ait , iS) / DS pace! p80 || g | wi | i | 8 | 3 | zi| | | LOT 44 | At BLOCK 3487 | | | SET 5/8" 1R& CAP }e PSM #6218 \I [ "Septic Plan approvel | Charlotte County Health Db Inspector __ bk ee WEF} A JACENT | Sep DAINFIELO | | Ci SWALE N60°38'31"E £3.00 (P&M ‘by HLT ant parinian . LOT 15 BEOCK 3 3467 (10, 378.00 o- 2 ~ PROPOSED 4 BDRM 2258 SF LVG FFE 53.92 MIN. 6' U&D EASEMENT re 83.00' (P&M) NO SUREACE WATER BOT, PO 7A BLE WATER 1% IR RIGA HOA! WELL. 18 éocarera wrt 75! of PRo PGRIY Line. fog S el N br} — Cit. SWALE —--—~; a SILT rence“| rr aN "20" PROPOSED *" DRIVEWAY | BSR ert DF @0 TANK (OR (MIN. 8° COVER) CAT.3 AL 1000 SF AREA UNOBSTRUGTED LOT 16 BLOCK 3467 —— SET 5/8" IR & PSM #6218 C/l-— ANITA AVE. 0 PUBLIC RW 20+ PAVED PLAN - SITE, DRAINAGE & SEPTIC Se ee a : f { , ) @ STATE OF FLORIDA PERMIT #. DEPARTMENT OF HEALTH ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM SITE EVALUATION AND SYSTEM SPECIFICATIONS APPLICANT: Vi7ALiy KIKTENKO AGENT: a ON EIA Si uot: /S prock:~376 7 supprvisron: O“/ SZc 7 FROPERTY ID. #: 12ZO0 3377 Of} [Secation/Township/Parcel No. or Tax ID Number] OS GI - 20 _ 220 TO BE COMPLE'TED BY ENGINEER, HEALTH DEPARTEMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINNEERS MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH OF SUBMITTAL. COMPLETE ALL ITEMS. PROPERTY SIZE CONFORMS TO SITE PLAN: (A) YES [ ] NO NET USABLE AREA AVAILABLE: O-2. 7 acres TOTAL ESTIMATED SEWAGE FLOW: o GALLONS PER DAY [RESIDENCES-TARBLE 1/OTHER-TABLE2] AUTHORIZED SEWAGE FLOW: ‘7. GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE] UNOBSTRUCTED AREA AVAILABLE: 70200 SOFT UNOBSTRUCTED AREA REQUIRED: 7OS°O — sort ~~ 70S 1 “Ys 0 BENCHMARK/REFERENCE POINT LOCATION: On anee 7 Se. A-CLCeE Riant Fle. [(50-60" ELEVATION OF PROPOSED SYSTEM SITE IS 40-3" [INCHES /FT] AB BELOW] BENCHMARK/REFERENCE SOINT THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES SURFACE WATER: /Y FT DITCHES/SWALES: 32 FT NORMALLY WET? [ ] YES [X%] No WELLS: PUBLIC: Ly, FT LIMITED USE: VLA Fr PRIVATE: Sf Fr NON-POTABLE: “VW bel FT BUILDING FOUNDATIONS: S'S’ pe PROPERTY LINES: /S‘ Pf POTABLE WATER LINES: Pr SITE SUBJECT TO FREQUENT FLOODING: [ ]. YES I no 10 YEAR FLOODING? [ ] YES [*] NO 10 YEAR FLOOD ELEVATION FOR SITE; NSA FI MSL/NGVD SITE ELEVATION: Vf _FT MSL/NGVD SOIL PROFILE INFORMATION site 1 S2'Zp SOIL PROFILE INFORMATION site 2 S2°4D MUNSELL #/COLOR TEXTURE DEPTH MUNSELL #/COLOR TEXTURE DEPTH $ oO” to 7” 10xR Sf} lan Oo” to 9” T ? To p* ks Ky * 70 73" AS (22 TO 3 * 70 EZ Fs Zu" £0 30° 7 _ AS Be tO ge __£s__ «Sa 80 “0” Ok AS 880 a2" PRE AY Gwafhl? 40" 20 257 AIR U4 VP be KRE A Gof "43" 00 03" Es PU (91RYS VP be ES spt t0 ez? : Ai go" TO. 72 LTRS bam gel Fa 62" 20 777 8G a TO USDA SOIL SERIES: HPPEO AI p43 aan hs USDA SOIL SERIES: wA7I%EN pt BGS Frayer hS OBSERVED WATER TABLE: 43” INCHES [ABOVE / @elOW) EXISTING GRADE. TYPE: [PERCHED / APPARENT] ESTIMATED WET SEASON WATER TABLE ELEVATION: so” INCHES (ABOVE / BELOW] _EXISTING GRADE HIGH WATER TABLE VEGETATION: [] yes [4] no MOTTLING: [A] YES [ ] NO DEPTH: 40." INCHES SOIL TEXTURE/LOADING RATE FOR SYSTEM srzInc: “4 f0'6S pepTH OF EXCAVATION: 24 "INCHES DRAINFIELD CONFIGURATION: [ ] TRENCH tAl BED [ ] OTHER (SPECIFY) REMARKS / ADDITIONAL RN RE- EDOK/ 6 VE FCATURES PB&IERVEO @ GO" jncHea LEtHW ; RWOE hi fYR Ye Wis v7LGR LATIN THE fYR 74 PIATAIR _, Carmen a OVS ACT Lo 3ITE EVALUATED BY: Piinnkn On deren, AEA S CLAY? onze: IAIULE eee em A en 2H 4015, 10/96 (Replaces HRS-H Form AO1S {page 3] which may be used) Page 3 of 4 7 , STATE OF Font dgsereirr # TH ‘ DEPARTMENT OF . “ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM - EXISTING S¥STEM AND SYSTEM REPAIR EVALUATION APPLICANT: Ve rag 1¥ KIKTEN Ko CONTRACTOR / AGENT: Mh Bea rp S EANG SG V/oe bor: /S BLocK: O44 7 suspiv. “CA/. fEe 7E ID#: 4/2 66 3377 0// SSS TO BE COMPLETED By FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR, OTHER CERTIFIED PERSON. SIGN AND. SEAT ALL SUBMITTED DOCUMENTS . COMPLETE ALL APPLICABLE ITEMS. COMPLETE TANK CERTIFICATION BELOW OR ATTACH LETTER FROM A PERMITTED SEPTAGE DISPOSAL SERVICE. = SES SS SS a Pr SXISTING TANK INFORMATION 100 ] GALLONS SEPTIC TANK/GPD aTU LEGEND: MATERIAL :COVRC7E BAFFLED :(Y)/ N] if J GALLONS sEPTic ranK/GppD aru LEGEND: MATERIAL: _ BAFFLED: [Y / N] [ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL: { ] GALLONS DOSING TANK LEGEND: __. MATERIAL: # PUMPS: [ ] SSS SS | CERTIFY THAT THE ABOVE NOTED TANKS WERE PUMPED on //4/O9, arve TR VOLUMES SPECIFIED, ARE STRUCTURALLY § AVE A [CSOLIDS DBFIRCTION DEVICE>/ OUTLET FILTER DEVICE ] INStaTrED. : AVIA F7 SFP 71 S GRVICE G/E LOFT JIGNATURE ENSED JONTRACTOR BUSINESS NAME DA’ “GRISTING DRAINFIELD INFORMATION oo , ’ ‘46S } souare rear PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES { ] Dimensions: /S° x 3v J SQUARE FEET SYSTEM NO. OF TRENCHES [ -] DIMENSIONS: _ x 'YPE OF SYSTEM: [ STANDARD [ ] FILLED (A] MOUND [ ] : ‘ONFIGURATION: [ ] TRENCH [M4] BED {J ‘ESIGN: [ZX] HEADER [ } D-Box [4] GRAVITY SYSTEM { ] DOSED sysvTEM MEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE 2.6" INCHES [ ABOVE YSTEM FAILURE AND REPAIR INFORMATION 2006 ) system INSTALLATION DATE TYPE OF WASTE [>] DOMESTIC [ ] COMMERCIAL -400 ] GPD ESTIMATED SEWAGE FLOW RASED ON (X] METERED WATER [ ] TABLE 1, 64E~6, FAC ITE { 1 DRAINAGE STRUCTURES [ }] POOL { ] PATIO / DECK [ } PARKING: ONDITIONS: [X ] SLOPING PROPERTY { ] ATURE OF [ ] HYDRAULIC OVERLOAD { ] sorns [ ] MAINTENANCE { ] SYSTEM DAMAGE AILURE: { ] DRAINAGE / RUN OFF [ ] Roors [ ] WATER Tapiz tj ALLURE t*] sewace ow GROUND [ ] TANK [ ] D BOX/HEADER [xX ] DRAINFIELD YMPTOM: {%] PLUMBING BACKUP [ ] EMARKS/ADDITIONAL CRITERIA SEP He —_____ JAMITTED By; TITLE/LICENSE fh ROA Cone tenn pare: 7/ 5/39 lar A : 4kKKEY ATTACHMENT ‘ f e STATE OF FLORIDA PERMre NO. DEPARTMENT OF HEALTH . ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM FFE PAID. —____ CONSTRUCTION PERMIT meneame CONSTRUCTION PERMIT FOR:. J New system I 1] Existing System [ ] Holding Tank [ ] ‘Innovative [ [A] Repair { ] Abandonment [ ] Temporary ee APPLICANT: Vi 7A zy AIK TEN KO EY EATEN KO property apprrss: 9320 A474 Nve, Frocewves g 74 $422 LOT: 18 BLOCK: 3 $7 SUBDIVISION: POA Sec TF : [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER] PROPERTY ID #: 4*/XOOS3 77 0// [OR TAX ID NUMBER] ae FON 03-4/-Z0 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 THR APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT oF THIS PROPERTY. es weeerectemon SYSTEM DESIGN AND SPECIFICATIONS : ATU t [£00 j catnons / GED SEPTIC TANK MULTI-CHAMBERED/IN-SERIES [Y ] : AT ] GALLONS / GED . CAPACITY MULTI-CHAMBERED/IN-SERIES [ ] bane 1 GALLONS GREASE INTERCEPTOR CAPACITY (MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS] Kf ] GALLONS DOSING TANK CAPACITY [ IGALLONS @ [ ] DOSES PER 24 HRS # PUMPS [ ] * + $1} Eber > {700 ] SQUARE FEET REPLACEMENT DRAINFIELD system 233 “ven. £7 O72 mes -/} IV AC &everh at ] SQUARE FEET SYSTEM \ TYPE SYSTEM: { ] STANDARD [ ] FILLED [>A] MouND { ] CONFIGURATION: [ ] TRENCH { AI BED c J Ct qT ? LOCATION or BENCHMARK: VXANGE ao7 CL. Altey Rra7 PIL ( S0-08’ Aivat's ; ELEVATION OF PROPOSED SYSTEM SITE [4/3] [INCHES/ET] (ABOVE BELOW] _BENCHMARK/REFERENCE POINT i BOTTOM OF DRAINFIELD TO BE {/.30] [INCHES/#T] [ABOVE BELOW] BENCHMARK/REFERENCE POINT ry ) FILL REQUIRED: [ ] INCHES EXCAVATION REQUIRED: [ ] INCHES 1 Kemnve CRMUNG ORATNFIGCY PNTCRIAL PAG Bod! IC/A-7EO SV PO/ES : © 39 "SINGER 7 KRADG tPA PPV KAM PICA PIE. t c PITA OVE0 ORAIN FIEED THR FCA? s . Con TRACTOR IPECIFICATIONS BY: ‘PPROVED BY: CharlotteCHD TITLE: saree ATE ISSUED: EXPIRATION DATE: — Se H 4016, 10/97 (Previous Editions May Be Used) ; Page 1 of 3 ) kK) EXISTING PROPOSED ITEM ELEVATION ELEVATION S260! Se: h0" Plumbing Stub S230! S2+ op’ tb k Inlet Invert S224! S$2+24' Tank Outiet invert (S8-40 S340" Top of Septic Tank S280 S2./2 "Top of Deana $/ 30" S780" otiom of Drainfeld S3-4u,! : S3-ye’ Existing Grade G7 30 4 730! Swale or Gutter Invert 4-20" OE2O , - Existing G i 48-87! 48-87" ESH.W.T. Sb-60" 52007 Qo. Re BENCHMARK LOCATION DR rvae 27 Ye ALLEY Kran? L/e- 60° f AU 6A BENCHMARK ELEVATION _ S00’ CA ) LIFT STATION? yes *~ No # ESH.WT. SEPARATION 27 (in) e 6 : Page | of 2 Charlotte County _ Property Appraiser | Real Property Record © If a discrepancy is discovered in your property's records, or those of another, please bring it to our attention immediately. General Parcel Information for 412003377011 pe Parcel (D: 412003377011 eons SE Address: 9320 ANITA AVE FEMA Flood Zone (Effective 5/5/2003) [Firm Panet |[ Floodway. ][ SFHA ][ Flood Zone |[_ FIPS COBRA Community || Baye Fon Elevation (ft. [un |[_1oan |[a20isc [copra our |[ 120061] O191F Four |{ x |[201sc || copra_our |[__ 120001 _| *If parcel has more than | flocd zone refer to the flood maps available on the GIS web site by clicking on View Map below. Click here| for definitions. For more information, please contact Building Construction Services at 941-743-1201. Sales Information [Dts] BootiPage [Sats CoderI[Seting Pre] 711996 _|{1484/538 11/2001 [1974/1152 liMPROVED —|[__$100 | [énnos |fa737A et VAC-MULTI $100 [672006 |299722 [vacant _|| $100 2009 Value Summary* | Land imprevemen ts Building = Total [Cost Approach [$7,309] $6,665|| $220,008 [$234,568] 568 income Approach ss [| — LC | a 500 [Market Approach [dL J WA [casted Vane ae WA Preliminary Value Summary,” as of January 1, 2009 * *Preliminary values within this box are NOT certified (final) values, Consequently, they can change periodically as records are updated. Notices of Proposed Property Taxes (TRIM Notice) are typically mailed mid-August and final values certified mid-October, Just Value reflects 193.011 adjustment, Non-School]| Schoo! | [_ Schoo! | Petes ee —— Just Value: $199,383 Soe ee Ownership current through: 7/30/2009 2008 Certified Tax Rol) Values, as of January 1, 2008 is] iy iu *Just Value reflects 193.011 adjustment. ee — School (Certified Just Value: $226,899 || $226,899 en) Coed oe) [Certified Assessed Value: | Assessed Value: [ $226,899 | [$226,299 | 899 [ns | eas | http:/Avww.ccappraiser.com/Show_parcel.asp?acet=4 !200337701 1 &gen=T&tax=T&bld=T&oth=T&sal-T&l.., 8/12/2009 f ( Cot @ e Page 2 of 2 Exempt Amount: $0 | $0 [Pretiminary Exempt Amount: IL $50,000|| $25,000 Land Information sti Land . Unit Unit Table/ Land - Land Improvement Information (See rerio id 1320_|[Paving Concrete (sq. Ft.) 1244 2007 1791 ||Residential Cost Walimounts (tow Cost) 2007 Building Information Buildi i aa — eS eS es [1 |[Duplex 2 units i 3.0_|{_ 0800_|[2007][2007][_1 10_|{_ 2266|[ 2266][ 3256 Building Appendage Information Building Component Information Year Code! Description Area [ior ached Gorge S57) [' | 736 |\Gatage Finish, Attached (SF) | 337 /2o07 9007 Enclosed Porch (SF), [| 7 Screened Walls 42 07 |, 2007 Enclosed Porch (SF), | 907 Screened Walls 42 12007 ||2007 [1 foo | Enclosed Porch (SF), (Plumbing Rough-ins (#) S Slab on Grade (% or SF) Lega] Description Short Legal L Legal Description PCH 074 3467 PORT CHARLOTTE SEC74 BLK3467 LT 15 UNREC WD 1484/538 1974/1152 2597/1231 2737/1161 0015 EAS2997/22 Data Last Updated: 8/12/2009- Printed On: Wednesday, August 12, 2009. Home @ Send Us Email (ew i[con| Description id [Ci [ame [Compostion Shingle | (i ](S51 Wamet& cooes aed [| 40109 fern [| nals Few Gne los] [1 ]f601 [Piumbing Fixtures (#) Copyright © 1997-2008 Charlotte County Property Appraiser. All rights reserved. http://www .ccappraiser.com/Show parcel.asp?acct=4 12003377011 &gen=T&tax=T&bld=T&oth-T&sal=T&... 8/12/2009 Charlie Crist Ana M. Viamonte Ros, M.D., M.P.H. Governor : State Surgeon General NOTICE TO APPLICANT Because of the requirements of chapter 556, Florida Statutes, Underground Facility Damage Prevention and Safety Act, itis mandatory that this office apply for and recaive a utility locate for your property prior to performing any site work on your property. it takes a minimum of 2 days, and up to five days to receive a locate ticket and if any of the required information on the ticket request is incorrect or missing, it will take fonger. We realize this will slow down the Permitting process. However, it is a necessary aid in preventing serious injury, and potential Service interruption. Therefore, it is imperative that we have your assistance in this process. Please ensure you have provided us with complete driving directions to your property, this must include the closest main intersection. Also, you must indicate anything that might prevent a locator from performing this service, for example a locked gate, or large dog, To ensure you have read and understand this notice, please date and sign the bottom of this page and attach it to your permit application. : Please note that private utilities are not located during this process. Any electrical.fines - installed under ground, Sprinkler lines, etc will not be marked by this process. Please indicate on the site plan any utilities you or previous owners may have installed. The Charlotte County Health Department is not responsible for damage caused to private property during the course of our evaluation or inspection process. , 1/8/09 Sign and ariwW A. Ga FLE~} _ Revised 6/6/07 KASHARED/OSTDS2007 : Charlotte County Health Department « Environmental Health 18500 Murdock Circle, Rm 203 » Port Charlotte, FL 33948-1094 Tel, (941) 743-1266 © Pax (941) 743-1533 Charlie Crist Governor Ana M. Viamonte Res, M.D., M.P.H. State Surgeon General YorN Y Name:_ Title: PROPOSED SITE INFORMATION 1. Is there any slope to your lot? ; Slope is the percentage of fall in a specified distance. If the property is flat, it has no slope. If the property has slope, indicate the direction with arrows. 2. Are there any public wells within 200 feet of your lot? 3. Are there any existing or proposed wells on ot within 75 feet of your lot? (Please indicate use, irrigation or drinking) 4. Are there-any lakes, streams, canals, ot standing water, on or within 75 feet . of your lot? Ifso, you must have the “mean annual flood line” determined by this office or a certified professional surveyor and mapper with experience in the determination of flood water elevation lines. If you wish to have this office determine, initial here . (Chapter : 381.0065(4)(i), Florida Statutes) 5. Are there any easements on your property? 6.. Are there any drainage features (Le. ditches, swales, drainage retention areas, storm water piping, or interceptor drains, ete.) on, or within 75 feet of your lot? ; ; 7. Are there any underground utilities located on your property such as sprinkler lines or electrical lines? : tern Sepne Ler VICE Serre lan FRAC 70K (owner, building contractor, septic contractor, other) Date: M67 &, 2009 If you marked “Y” next to any of the above questions, please draw and locate on your site plan(s). _ revised SFO? 10/2f2007 . -KASHARED\OSTDS2007 Charlotte County Health Department « Environmental Health 18500 Murdock Circle, Rm 203 » Port Charlotte, FL 33948-1004 Tel. (941) 743-1266 ¢ Fax (941) 743-1533 Charlie Crist Ana M, Viamonte Ros, M.D., M.P.H, Governor State Surgeon General ATTACHMENT A EXISTING SYSTEM/MODIFICATION PAIR INSTRUCTIONS FOR COMPLETING AND SUBMITTING YOUR SEPTIC PERMIT : APPLICATION certification (DH 4015, page 4 of 4) that must be submitted to this office with your application. If your tank(s) have been pumped and certified within the last 3 years, and you have the proper paperwork, you don’t have to have them pumped again. 2. Site information sheet and application filled out completely, signed and dated. 3. Site plan ~ This is the most important part of your application, please take the time to ensure you have ail features accurately depicted. The site plan (signed and dated) must . show exactly what you Propose to do on the site. See below: : Draw the location, and show dimensions of lot boundaries, You must show building location, potable and non-potable waterline, any easements, roads, obstructions, wells (on said, and all adjacent properties), surface water, driveways, walkways, the location of both existing and Proposed tank(s), and drainfield. In addition to the location, indicate the estimated distance to all said features. You must show location of any private utilities that have been installed on the to private property; underground utilities must be indicated to the CCHD so we can take action to avoid them. This is a safety concern as well as possible interruption of service. FOR EXISTING OR MODIFICATION PERMITS ; 4. Floor plan — Attach a copy of both the existing, and proposed floor plan for your house, Mobile or Manufactured home, or business. —- 3. . Permit Fees: Existing system application $180.00 ; Repair system application $360.00, CCHD site evaluation 525.00 Modification without tank replacement system application $380.00 Modification with tank replacement system application $430.00 (Modifications with CCHD performing sitet existing evaluation add 165.00) APPLICATION PACKAGES WILL BE CHECKED FOR ACCURACY PRIOR TO ACCEPTANCE, INCOMPLETE APPLICATIONS CANNOT BE ACCEPTED. Thave read the above and understand the aforementioned regulations. 18500 Murdock Circle, Rm 203 « Port Charlotte, FL 33948-1094 Tel. (941) 743-1266 # Fax (941) 743-1533 ZL tg g Z ie ; Fez Wy A GUK CY i Charlotte County Health Department « Environmental Health ATTACHMENT { ( ome @ @ Receipt Number: R_080480_09082009_6 Encounter# E080480-09082009-0006 Date: 09/08/2009 12:03:46 , ENVIRONMENTAL HEALTH Fee Scale: % 18500 MURDOCK CIRCLE Cashier: VLC PORT CHARLOTTE FL 33948 PHONE: (941)743-1266 .FEDERAL TAX ID#: 593502843 . * CLIENT RECEIPT Name: 9320 Anita - 09-430RP. : DOB: Address: . City/State/ZIP: Previous Balance: $360.00 : So Vr oF ve Date Code Provider Amt | Amt | Amt jAmt Due Type 1092 REPAIR NO SE : {| i 165.60 NO94REPAIRPERMITSEPTIC.OCSCSsC“‘“‘“‘; B bat 2 3 [en re} y 4 o fo) 6 <4 Ss &. x rey Qo 3 Ne} 092 REPAIR NO SE . vanes | Paes] [ow 8 Amount Received $ 360.00 Amount Paid $ 360.00 Change Given $ 0.00 Current Balance $ 0.00 PAYMENT IS DUE ON THE DAY SERVICES ARE RECEIVED. Check out our new web site www.CharlotteCHD.com INVIN2:3rd Party Insurance/MC PY: Payor Fw:Fee Waived MD: Medicaid CL: . Client ¥R: Fee Reduced OTH: Other Insurance . CCI%:Client Coinsurance % FI: Fee Increased ed . {a aale Address 9320 Anita Ave . nd Og ; Get Google Maps on your phone Goc le maps Englewood, FL 34224 Gp ethers MAPS 1466453 Gay ? . . \ . : 2329 anita ave englewood fl - Guu, ‘aps @ . Page | of | | | | | i http://mans.google.com/mans?f=a&source=s a&hi=en&geocode=&a=9320+anitatavetenglewood+fl&sll=37.... 8/12/2009 09/08/2009 08:36 FAX { : 003/004 [tp x cather Guery UOiMas,. a 3.1] FeNOV2008 ~ <<: _ 1 OCT-2008 ssp. df ; _e ~ PTAUG-2008 Q222 Anita Aue, 09/08/2009 09:41 FAX ‘QMeter 1 listaryfeathe Whe 3.710 CUPROLA “[aTAN-2005 fe-DEC-2008 18-NOV-2008 ~~ fel-DET-2008 19-SEP-2008 ARO Anita Aus, e 6 Charlie Crist Ana M. Viamonte Ros, M.D., M.P.H. Governor ‘State Surgeon General September 25, 2009 Vitaliy Kiktenko 9320 Anita Ave. Englewood, FL 34224 The Department of Health is reviewing open septic permits on repairs for compliance. A representative of the Department did an inspection of your septic system located at 9320 Anita Ave., Englewood, FL on _9/25/09_, and discovered that your system is not in compliance with Florida Administrative Code 64E-6. In order to properly close this permit the following actions must be completed: Actions to take 1. Have the drainfield area stabilized by adding sod or Hay and grass seed, this will prevent the soil from washing away. - When the above mentioned corrections are completed please call the Department of Health at the below number so we can inspect the system. Thank you for your help in this matter, and your time. If we can be of any assistance do not hesitate to call. Sincerely, Shawn E. Wilson Environmental Specialist II Charlotte County Health Department Reference #: 09-430RP Ce: Martin Septic Service Inc. . 2308 Tropicaire Blvd North Port, FL 34286 Charlotte County Health Department » Environmental Health 18500 Murdock Circle, Rm 203 * Port Charlotte, FL 33948-1094 Tel. (941) 743-1266 * Fax (941) 743-1533 _ Revised 2.27.2007 OL ft . Penmit # ~ Installer: Applicant: _ : tems with“ are OK. Items marked with “X” are not OK Jtems circled giesih Inspection. Items marked with “--” are not applicable, — Septic Tank N/ATU S| ; Setbacks 01 Capacity: era faiae) 02 [4 [] Material: Conc []FG [] Pol a 03 Outlet device: 90 Sweep [ ] Filter: 29 [ EE] Private Well: __ Ft. 04 Partition Material: Cone [J FG [] Pol H Private. Well 25° Setback to Stem Wal ig 05 Legend: 130-4 FL 06 _{) [] Watertight/ Tamper Resistant Covers/inlet seal 30 [44 Public Well: Ft 07 _{[}-[] Level: . 31 [4-4] Imigation Well: Ft: 08 see filled/mound systems ~_ | 32 [41] Potable Water Lines: Ft.. Dosing Tank (s) / Trash 33 [47[ ] Building Foundation: °°3""_ i oy -H Capi 34 Prope Lines: /¥ 02) ial: \(]Cone Ti FG Tj Poy LSP ¢ of eee ae Parent “Z 94 Ft BULL tegen Sg ge of Draiffed to Tank ree - CLO] Pump Types 7 Pan - CU Floats gi “infield Cover (18 OLE apa . V5 iY TN eae 2. Material -f]Cone—(JFG {jPoy 138 CT 03 Outlet Bl Come LEE LE 1139 fa (f Stbization Material: PSoll[] Hay/seed [TAR | 05 Legeti [40 py Titres: PT Drives f Drainfield (s) \ 40,1 Unpbstructed Area vB 7a WE Oa aes sgh ATE 1S Ware Cosas TO TOM by ede [jase ox ae Ge Tf | Number of drainlines: PF BA7 «42 TL] Ando and Visual Alarm 12 rainline separation ; 43 Annual Operation Permit —B drainline slope (1” per 0} ] i g 15 Elevation / ¢'’ Ft.[Above]/[Bwkew] BM 44 | Building Area 16 7T | System Location: P{As Permitted [ |No sessile plan | ampling Port 47{Y{ | Contractor MAavie “148 [4 ] # of MPS —[4¥] Bundles oy 18 & 21 FT] Aggregate: ) gprepate Washed/Ciean . : 48 EF ot Ca “FE J8q. % ; . Type: Eq 36 Bio 3 Other: Fill / Excavation Material 22 Fil Amount : : 23 (4 [] Texture fdonment w (Y [] Excavation Depth ‘Rumpe Excavation Area S0{l []Ts 3 Oe Midpoint Not ot OK/ OK Date: «Bed: Nott _— Ge _ Dates — inte Midpoint K /OK . Date: . Bed: Not OK / . Final Not OS) au —4e7 Date axe Final Not OK sy _ Final Approval AHEEET specialist POW AGA. Date: a py ' Fastin <7 [ ]Gutters [ ]Gutters IMA &OP |[]MA& OP [IMA&OP |[}]MAgeop | ] f]. - 1 [ [YOK Yt Joker" [ INotOK |{ JNotOK | INotoK Additional Information Note: clean up after a discharge will) result i ina a $50. 00 charge which will be. added to the monthly bill. Discharge hours are 24 hours/7 days a week. : 3. All information requested on this and any ‘other form mast. be complete and accurate without exception. 4: iti As very important when the grease switch is ON and you have completed unloading ‘that you u turn your key OFF and get a receipt before turning the switch back to REGULAR. - ; ; a ae COMPOSITE x : ok . ey ; ATTACHMENT E WHITE-CCU YELLOW-HAULER | PINK-HEALTH DEPT. 03/13/03 merrier tT. ware nett a VRILOW-HAULER’ .- / - ",” PINK-HEALTH DEPT, ee pate Oo dele deta de ede ae te ak 1. Failure to clean " after a discharge will Fesult i a $50.00 charge which will be added to the monthly bill. 2. Discharge hours are 24 ‘hours/7 days a week. 3.. All information requested on this and any ‘other form must be complete and accurate without exception, 4. Itis very important when the grease switch is ON and you have completed unloading that you turn your key OFF ‘and get a. receipt before turning the switch back to REGULAR. : rn mY WHITR-CCU -YELLQW-HAULER . PINK-HEALTH DEPT. "93/13/03: © . Truck Ca PINK-HEALTH DEPT. . Failure to clean up after a discharge will result i in a 2 50. 00 charge which will be added ‘to the ‘inonthly bill. ge Discharge hours are 24 hours/7 days a week. . ; a : - : a All information requested 01 on this and any other form must be complete and s accurate without exception. : It i is very. important when the grease switch is ON and you 1 have completed unloading that you turn your key OFF ... and get a receipt before corning the switch back to REGULAR. Te ae WHITRICOIT “* YELLOW-HAULER. -. > PINK-HEALTH DEPT. nanaina® ‘L. Failure to clean up after a discharge will resultin a $50.00 chatge which will be added to the monthly bill. 2. Discharge hours are'24 hours/7 days a week. 3. All information requested on this and any other form must be complete and ‘accurate without exception. 4, Iti is very important when the greasé switch is ON and you have completed unloading that you turn your key.OFF and get a-receipt before turning the. switch back to REGULAR. : WHITE-CCU YELLOW-HAULER 03/13/03 - Iti is very important when the grease ewiteh i is ON. and you have comple and get a: + receipt before turning the switch back‘ to REGULAR, WHITE-CCU . YELLOW-HAULER Bn ALTH DEPT. ; 03/13/03 Charlotte ‘County Utilities Tim Arrived Discharge Permit 4, “witrricc = eo “YBLLOW-HAULER" \ "° PRNK:HEALTH DEPT. SEPTIC | WHITE-CCU . YELLOW-HAULER : PINK-HEALTH DEPT. . Laai3i03 ‘iat : a 2 | Note: . h ‘1, Failure to clean up after a discharge will result in a $50.00 charge which will be added to the monthly bill. F 4. It is very important when the grease switch is ON and you: have completed unloading that you turn your key 0 OFF. : “and get a receipt pefore: turning the sch back to REGULAR. . ny Dee Aur rete ep. PINK-HRATTH DEPT. 20-7) narnia Charlotte County Utilities —. "In-County" | Transport Waste Hauler Manifest TYPE OF DISCHARGE: . eosin iootiadiaitisioot tion ia nicki ibniaciodi io ica a ia aR a . “ Note: a — ; ee Failure to clean up after a discharge will result in a $50.00 charge which will be added to the monthly bill. 2, Discharge hours.are 24 hours/7 days a week. 3. All information requested on this and: any ‘other form must be complete and accurate without exception. 4. Itis very imp ortant when | the grease switch i is ON and you have completed unloading ¢ the it you turn your key OFF and get a receipt before tarning the switch hack to ‘REGULAR. vIny URATTU-NEDT fa * sree nae tr Failure to clean up after a discharge will result i ina 850. 00 charge ¥ which will be added to the monthly bill. Discharge hours are 24 hours/7 days a week, All information requested 0 on this and any other form must be complete. and accurate without exception. Iti is very. important when the grease switch is ON and you have completed unloading that you turn your key OFF and get a receipt before turning the ‘switch back to REGULAR. WHITE-CCU YELLOW-HAULER . PINK-HEALTH DEPT. 03/13/03

Docket for Case No: 10-000041PL

Issue Date	Proceedings
Feb. 15, 2010	Order Relinquishing Jurisidiction and Closing File. CASE CLOSED.
Feb. 15, 2010	Settlement Agreement filed.
Feb. 15, 2010	Motion to Relinquish Jurisdiction filed.
Jan. 21, 2010	Order of Pre-hearing Instructions.
Jan. 21, 2010	Notice of Hearing (hearing set for March 5, 2010; 9:00 a.m.; Port Charlotte, FL).
Jan. 21, 2010	Request for Copies filed.
Jan. 14, 2010	Petitioner's Request for Production of Documents to Respondent filed.
Jan. 14, 2010	Petitioner's First Set of Interrogatories to Respondent Martin Guffey filed.
Jan. 14, 2010	Petitioner's Request for Admissions filed.
Jan. 12, 2010	Petitioner's Notice of Production from Non-party filed.
Jan. 11, 2010	Joint Response to Initial Order filed.
Jan. 06, 2010	Administrative Complaint filed.
Jan. 06, 2010	Respondent's Answer to Administrative Complaint and Petition for Administrative Hearing and Appeal filed.
Jan. 06, 2010	Notice (of Agency referral) filed.
Jan. 06, 2010	Initial Order.