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- STATE OF FLORIDA PERMIT #
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING'SYSTEM AND SYSTEM REPAIR EVALUATION
APPLICANT:
CONTRACTOR / AGENT 4!► n
LOT: BLOCK: --(( r��( ID#: � e�yJ (a
sUBDIv: �,
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TAM CONTRACTOR OR
I OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS.
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
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EXISTING TANK INFORMATION
GALLONS SEPTIC TANK/GPD ATU LEGEND: MATERIAL-
GALLONS SEPTIC ,TANK/GPD ATU LEGEND: MATERIAL: BAFFLED:1Y
[ ] GALLONS GREASE INTERCEPTOR LEGEND: MATERIAL:
[ } GALLONS DOSING TANK LEGEND: MATERIAL: #'PUMPS: 1, }
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON;—)
THE VOLUMES SPECIFIED AS DETERMINED By .{ Dno4mlms / F27rLING / LEGEND }, ARE FAft
'O�F OBSERVABlZ
CTS OR HAVE A { SOLIDS O EVI / L T FDEVICE� } I '.
SI TUBE OF LICENSED CONTRACTOR BUSINESS NAME DATE
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TING DRAINFIELD INFORMATION
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{ } SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES { } DIMENSIONS. X
{ } SQUARE FEET SYSTEM NO. OF TRENCHES { } DIMENSIONS: x
TYPE OF SYSTEM: [ } STANDARD { ] FILLED { } MOUND [ }
CONFIGURATION: { ] TRENCH { } BED { J
DESIGN: { } .HEARER [ ] D-BOX [ 1 GRAVITY SYSTEM { } DOSED SYSTEM
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE INCHES I ABOVE / 1BELOW}
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SYSTEM FAILURE AND REPAIR INFORMATION
[ } SYSTEM INSTALLATION DATE. TYPE OF WASTE [ } DOMESTIC { } COMMERCIAL
[ } GPD ESTIMATED SEWAGE FLOW BASED ON [ ] METERED RATER { } TABLE 2, 6494, FAC
SITE [ }. DRAINAGE STRUCTURES { } POOL { } PATIO / DECK { ] PARKING
CONDITIONS: { } SLOPING PROPERTY [ } I
NATURE OF { ] HYDRAULIC OVERLOAD { } SOILS { } MAINTENANCE { 7 SYSTEM DAMAGEI
FAILURE: { } DRAINAGE / RUN OFF { } ROOTS { } WATER TABLE { ]
FAILURE { } SEWAGE ON GROUND [ } TANK [ } D BOX/HEADER { DRAINFIELD
SYMPTOM: { } PLUMBING' BACKUP { }
REMARKS/ADDITIONAL CRITERIA
SocAod 01I
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SUBMITTED BY: � � �.' -- - _ TITLE/LICENSE f-
DH 4015, 08/09 {Obsoletea revious editions which may not be used}
Incorporated 64E-6.001, ! Page 4 of 4
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834-1724
Septic Services
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