00-0115-003 Notification for Use of the General Permit ter Construction of are_Extension to a Public Drinking Water
Distribution System -
Project Name: -
Permittee: =�(L
I, the undersigned owner or authorized representative*of ��1=
certify that all water main pipe, fittings;'valves, fire hydrants, a))d re;ated: roducts that will be installed under this project and that
will come into contact with drinking wz-ter conform,or will r;onferm, with American National Standards Institute/NSF International
Standard 61.
I agree that we will require the contractor to furnish us with record drawings for this project. Also, I agree that we will retain a
professional engineer registered in.Florida to inspect construction of this project for the purpose of determining if work proceeds
in accordance with the construction permit and approved engineering plans and specifications.
I am fully aware that we must obtain a letter of clearance from the Department before we place this project into service for any
purpose other than disinfection or testing for leaks. Also, I am fully aware that, if we sell or legally transfer ownership of this
project before/obtaining a letter of clearance from the Department, we must submit to the Department an"Application•.for Transfer
of a Publi ater S tam C r c'on Permit"within 30 days after such sale or legal transfer of ownership.
Signat re a;fnd Date Name and itle (please type or print)
"Attach a letter of aut r
r • •
DADE
I, the undersigned owner or authorized representative' of
certify that we will provide the potable water supply required by this project. As in ica a elo , t reatment plant to
which this project will be connected has the capacity to provide the potable water supply required by this project, and I certify that
said plant is in compliance with the standards and criteria set forth in Chapters 62-550, 62-555, and 62-560, F.A.C. Also, said
plant was constructed under one or more valid Department construction permits as indicated below, and I certify that connection
of this project to said plant will not be a violation of any condition of this(these) construction permit(s).
!Name of Water Treatment Plant to Which this Project Will Be Connected: LEXfIAID 6e UAPR
!4p4AATiX6- i Permit Number(s) for Plant and Date(s) Permit(s) Issued:
!Permitted Maximu ay c' of Plant: Z!�'
!Maximum Day F a Recorded on Monthly Operating Reports During Past.12 Months: /9/• 5
r" RICK WERRERN P.E.
Ivision
Signature and N % d t
i e an apartment
t
Miami-Dade 8f8t Sewer
Attach a letter of authorization.
I, the undersigned owner or authorized representative*of
certify that we will be the owner/operator of this project after it is placed into service. I agree that we will operate and maintain
this project in a manner that will comply with Chapters 62-550, 62-555, 62-560, and 62-699, F.A.C. Also, I agree that we will
promptly-*notify the Department if we sell or legally transfer ownership of this project.
Signature and Date Name and Title (please type or print)
Attach a letter of authorization.
I, the undersigned professional engineer registered in Florida, certify that I am in responsible charge of the preparation and
production of engineering documents for this project; that I have expertise in the design of water distribution systems;
DEP Form 62.555.900(7) Page 2of 5
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