STATEMENT OF COMPLETION AND REQUEST FOR

TRANSFER TO OPERATION ENTITY

SOUTHWEST FLORIDA
WATER MANAGEMENT DISTRICT

2379 BROAD STREET, BROOKSVILLE, FL 34604-6899

(352) 796-7211 OR FLORIDA WATS 1 (800) 423-1476

Within 30 days after completion of construction of the surface water management system, the owner or
authorized agent must submit the original plus one copy of this form and two complete sets of certified as-built
drawings for the surface water management system structures and appurtenances. Upon receipt, this Statement
of Completion will be reviewed and the system may be inspected for compliance with the approved permit and as-
built drawings. The operation phase of this permit is effective when the Statement of Completion form is signed
by an authorized District representative.

1. SURFACE WATER MANAGEMENT SYSTEM INFORMATION:

Permit No.: __________________________________ County: ___________________________________

Project Name: ________________________________ Permittee: _________________________________

Address: _______________________________________________________________________________

City, State, Zip: _____________________________________ Telephone: ( )___________________

2. I HEREBY CERTIFY THAT (please choose accurately and check only one box):

A. At the time of final inspection, the surface water management system was completed substantially in
accordance with the permitted construction plans and information. Any minor deviations from the
permitting plans and specifications will not prevent the system from functioning in compliance with the
requirements of Chapters 40D-4 and 40D-40, Florida Administrative Code (F.A.C.). (The as-built
drawings and information submitted to the District shall confirm this certification.)

B. At the time of final inspection, the system was NOT completed in substantial conformance with the
permitted construction plans and information. (The registered professional engineer shall describe
the deviation(s) in writing, and provide confirming depiction on the as-built drawings and information.)

This certification shall be verified by TWO COPIES of attached "as-built" drawings (as-built drawings must be
signed, dated and sealed by a Florida Registered Professional Engineer or Professional Land Surveyor and
Mapper, as required by State Law).

By: _________________________________________ _____________________________________________

Signature of Engineer of Record Name (please type) Fla. P.E. Reg. No.

• AFFIX SEAL • _____________________________________________

Company Name

Date: _______________________________________ _____________________________________________

mm/dd/yyyy Company Address

Phone: ( )_______________________________ _____________________________________________

City, State, Zip

FORM 547.27/SOC (Rev. 02/07)

Rule 40D-1.659, F.A.C. Page 1 of 3
3. NOTIFICATION OF COMPLETION: The District is hereby notified that construction of the surface water
management system is completed, and the Permittee requests that the surface water management permit be
transferred to the legal entity (individual owner or corporate) responsible for operation and maintenance
(O&M) as named in Section 4. An authorized agent must submit a letter of authorization from the permittee
authorizing him or her to execute this Notification.

By: __________________________________________ __________________________________________

Signature of Permittee or Authorized Agent Name and Title (please type)

__________________________________________ __________________________________________
Permit Number Company Name

__________________________________________
Company Address

__________________________________________
City, State, Zip

4. AGREEMENT FOR SYSTEM OPERATION AND MAINTENANCE RESPONSIBILITY: The below-named

legal entity responsible for O&M agrees to operate and maintain the surface water management system in
compliance with all permit conditions and the provisions of Chapters 40D-4 and 40D-40, F.A.C. An
authorized agent must submit a letter of authorization from the owner or other legal entity authorizing him or
her to execute this agreement.

By: __________________________________________ __________________________________________

Signature of Representative of Acceptable Name of Owner or Other Acceptable
O&M Entity or Authorized Agent Legal Entity for O&M

__________________________________________ __________________________________________
Name and Title (please type) Address

__________________________________________ __________________________________________
Permit Number City, State, Zip

__________________________________________
Phone Date

RESPONSIBILITY FOR OPERATION AND MAINTENANCE MAY BE TRANSFERRED TO ANOTHER ENTITY ONLY
UPON WRITTEN NOTICE AND APPROVAL BY THE DISTRICT IN ACCORDANCE WITH RULE 40D-4.351, F.A.C.

AGENCY USE ONLY

OPERATION AUTHORIZATION: Based upon the certification by the Engineer of Record in Section 2., and the notice of
completion in Section 3., the responsibility for operation and maintenance of the system is transferred to the legal entity
named in Section 4., and the operation phase of this permit is effective on the date indicated below.

SOUTHWEST FLORIDA WATER MANAGEMENT DISTRICT:

_________________________________________________________________________________________________
Authorized District Representative Name and Title

_________________________________________________________________________________________________
Effective Date (mm/dd/yyyy) Permit Number

FORM 547.27/SOC (Rev. 02/07)

Rule 40D-1.659, F.A.C. Page 2 of 3
 AS-BUILT DRAWINGS AND INFORMATION CHECKLIST

Following is a list of information that is to be verified and submitted by the Engineer of Record in support of the
Statement of Completion.

1. On behalf of the permittee, the Engineer shall certify that:

a. At the time of final inspection, the surface water management system was completed substantially in
accordance with the permitted construction plans and information. Any minor deviations from the permitting plans
and specifications will not prevent the system from functioning in compliance with the requirements of Chapters
40D-4 and 40D-40, F.A.C. (The as-built drawings and information submitted to the District shall confirm this
certification.); or

b. At the time of final inspection, the system was NOT completed in substantial conformance with the
permitted construction plans and information. (The registered professional engineer shall describe the
deviation(s) in writing, and provide confirming depiction on the as-built drawings and information.)

2. The Engineer's certification shall be based upon on-site observation of construction (scheduled and
conducted by the professional engineer of record or by a project representative under direct supervision) and
review of as-built drawings, with field measurements and verification as needed, for the purpose of determining if
the work was completed in accordance with original permitted construction plans, information and specifications.

3. The as-built drawings are to be based on the District permitted construction drawings revised to reflect any
changes made during construction. Both the original design and constructed condition must be clearly shown.
The plans need to be clearly labeled as "as-built" or "record" drawings. As required by law, all surveyed
dimensions and elevations required shall be verified and signed, dated and sealed by a Florida registered
professional surveyor and mapper or professional engineer. The following information, at a minimum, shall be
verified on the as-built drawings, and supplemental documents if needed:

a. Discharge structures - Locations, dimensions and elevations of all, including weirs, orifices, gates,
pumps, pipes, and oil and grease skimmers;

b. Side bank and underdrain filters, or exfiltration trenches - locations, dimensions and elevations of all,
including clean-outs, pipes, connections to control structures and points of discharge to receiving waters;

c. Storage areas for treatment and attenuation - dimensions, elevations, contours or cross-sections of all,
sufficient to determine stage-storage relationships of the storage area and the permanent pool depth and volume
below the control elevation for normally wet systems;

d. System grading - dimensions, elevations, contours, final grades or cross-sections to determine

contributing drainage areas, flow directions and conveyance of runoff to the system discharge point(s);

e. Conveyance - dimensions, elevations, contours, final grades or cross-sections of systems utilized to divert
off-site runoff around or through the new system;

f. Water levels - existing water elevation(s) and the date determined;

g. Benchmark(s) - location and description (minimum of one per major water control structure); and

h. Wetland mitigation or restoration areas - Show the plan view of all areas, depicting a spatial distribution of
plantings conducted by zone (if plantings are required by permit), with a list showing all species planted in each
zone, numbers of each species, sizes, date(s) planted and identification of source of material; also provide the
dimensions, elevations, contours and representative cross-sections depicting the construction.

4. Submit the final subdivision plat or other legal documents, as recorded in the county public records, showing
dedicated rights-of-way, easement locations and special use areas that are reserved for water management
purposes and continuing operation and maintenance.

5. Additional information will be shown on the as-built drawings or otherwise provided as needed to verify and
support the Statement of Completion (example: home owners association final documents, and other items
required by permitting conditions.)

FORM 547.27/SOC (Rev. 02/07)

Rule 40D-1.659, F.A.C. Page 3 of 3