HomeMy WebLinkAboutSewageSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
CONSTRUCTION PERMIT FOR:
APPLICANT: (St Lucie Habitat)
OSTDS New
PERMIT #:56-SP-2038669
APPLICATION #:AP1467508
DATE PAID:
MAY U 5 ,�ZO
ST. Lucie Couno/, Permitting j
FEE PAID:
ECEIPT #:
#:.PR1305118 -
PROPERTY ADDRESS: TBD Palm Dr Fort Pierce, FL 34982
LOT: 30 BLOCK: 61 SUBDIVISION: Indian River Estates
PROPERTY ID #: 3402-609-0348-000-3 [SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
[OR TAX ID NUMBER]
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 THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL,
STATE, OR LOCAL PERMITTING REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND
T [
900 ]
GALLONS / GPD Septic New
CAPACITY
A [
]
GALLONS / GPD N/A
CAPACITY
N [
]
GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK:1250 GALLONS]
K [
]
GALLONS DOSING TANK CAPACITY [
]GALLONS @[ ]DOSES PER 24 Has #Pumps [ ]
D [ 375 ] SQUARE FEET Drainfield New SYSTEM
R [ ] SQUARE FEET N/A SYSTEM
A TYPE SYSTEM: [ ] STANDARD [ ] FILLED [x] MOUND [ ]
I CONFIGURATION: [X] TRENCH [ ] BED [ ]
N
F LOCATION OF BENCHMARK: Orange paint spot SE Comer Of water meter SE property Corner
I ELEVATION OF PROPOSED SYSTEM SITE [ 1.00 ][ INCHES FT ][ABOVE 413ELOWJ BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 4.00 ][INCHES FT ][ABOVE BE LOW] BENCHMARK/REFERENCE POINT
L
D
O
T
H
E
R
REQUIRED: 123.001 INCHES EXCAVATION REQUIRED: [ 4O.UUI 114UU45
system is sized for 3 bedrooms with a maximum occupancy of 6 persons (2 per bedroom), for a total estimated flow of
gpd•
SPECIFICATIONS BY: Hunter A Collier TITLE: Environmental Specialist I
APPROVED BY: • ten` �C ���.� TITLE: Environmental Specialist I St. -Lucie CED
Bunter A Collier
DATE ISSUED: 02/25/2020 EXPIRATION DATE: 08/25/2021
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated: 64E-6.003, FAC Page 1 of 3
v 1.1.4 AP1497508 SE1254606
NOTICE OF RIGHTS
A party whose substantial interest is affected by this order may petition for an
administrative hearing pursuant to sections 120.569 and 120.57, Florida Statutes. 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 A-02, Tallahassee, Florida 32399. The Agency
Clerk's facsimile number is 850-413-8743.
Mediation is not available as an alternative remedy.
Your failure to submit a 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, Florida Statutes. 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.
St. Lucie County Health Department
5150 NW Milner Dr Port Saint Lucie, FL 34983
HEALTH
PAYING ON: s:56-SF-2038669 Bi«ooc#:56-BID-4552190 CONSTRUCTION APPUCATICNMAP1467508
RECEIVED FROM: ASHTON SEPTIC TANKS, INC. AMOUNT PAID: $ 545.00
PAYMENT FORM: CHECK 1642 PAYMENT DATE: 02/12/2020
MAIL TO: (St Lucie Habitat)
FACILITY NAME:
PROPERTY LOCATION:
TBD Palm or
Fort Pierce, FL 34982
Lot: 30 Block: 61
Property ID: 3402-609-0348-000-3
EXPLANATION or DESCRIPTION:
QUANTITY
FEE
128 - OSTDS Construction System Inspection Research Fee
1
$
5.00
-1 - Surcharge (All)
1
$
45.00
-1 - OSTDS New Permit Surcharge
1
$
100.00
-1 - OSTDS Construction Application and Plan Review,New
1
$
100.00
123 - OSTDS. Construction Site Evaluation
1
$
115.00
126 - OSTDS Construction Permit (New or Mod, Amendment)
1
$
55.00
127 - OSTDS Construction System Inspection
1
$
75.00
133 - OSTDS Construction Reinspection
1
$
50.00
RECEIVED BY: MontanezNM AUDIT CONTROL NO. 56-PID-4292229
}
-STATE OF FLORIDA
z DEPARTMENT OF HEALTH
�' ONSITE SEWAGE THE TNENT AND DISPOSAL
SYSTEM
��0Dp8'`¢ APPLICATION FOR CONSTRUCTION PERMIT
PERMIT NO. 5tp—SF—a�38lals-1
DATE PAID: Z 11 3� 'I^•
FEE PAID: I(Qc.(2
RECEIPT a:
APPLICATION FOR:
pi] New System
[ ]
Existing System
[ ] Holding Tank [ ] Innovative
[ I Repair
[ I
( ] Temporary C ]
j C
'^' L
`Ab`andjonment_L
FAA �J r (47t,
APPLICANT:
AGENT: 'AS6`
-M
sp P4lC.
�FY►1TY�S
�iJY,1'�.
MAILING ADDRESS:
-ILO
Cvrlovie_.11r_
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Re- CL
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. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION 1
LOT: '710 BLOCK: %I SUBDIVISION: ZYj,�y� I?I4 �V �SY'19�C5 6 PLATTED:
PROPERTY ID n: 3iD2 -(009 -O3Y0 -cm ZONING: I/M OR EQUIVALENT: [ Y / N ]
PROPERTY SIZE: r2 3 ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC D<j<=2000GPD [ ]>2000GPD
IS SEWER AVAILABLE AS PER 381..0065, FS7 C Y /Q] DISTANCE TO SEWER: _IkA_FT
j
PROPERTY ADDRESS: �1'.iG%(m
DIRECTIONS TO PROPERTY:
BUILDING- INFORMATION
Unit Type of
No Establishment
2 5;1�
3
4
P-q RESIDENTIAL [ I COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1 Chapter 64E-6, FAC
3 13
[ ] Floor/Equipment Drains
/ [ ] Other (Specify)
0
SIGNATURE: IV DATE:
DH 4015, 08/0 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, PAC Page 1 a£ 4
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATION
APPLICANT: St Lucie Habitat
CONTRACTOR / AGENT: ASHTON SEPTIC TANKS, INC.
LOT: 30 BLOCK: 61
SUBDIVISION: Indian River Estates ID#: 3402-609-0348=000-3
APPLICATION # AP1467508
PERMIT # 56SF-2038669
DOCUMENT # SE1254606
TO BE COMPLETED BY ENGINEER, REALTH DEPARTMENT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEERS MUST PROVIDI
REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO NET USABLE AREA AVAILABLE: 0.23 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 300 GALLONS PER DAY [ RESIDENCES -TABLET / OTHER -TABLE 2 ]
AUTHORIZED SEWAGE FLOW: 575.01. GALLONS PER DAY [ 1500 GPD/ACRE OR 2500 GPD/ACRE ]
UNOBSTRUCTED AREA AVAILABLE: 750.00 SQFT UNOBSTRUCTED AREA REQUIRED: 750.00 SQFT
BENCHMARK/REFERENCE POINT LOCATION:
meter SE
ELEVATION OF PROPOSED SYSTEM SITE 1.00 [ INCHES / FT ] [ ABOVE / BELOW ] BENCSMARK/REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: FT DITCHES/SWALES: 15 FT NORMALLY WET: [ ]YES [X]NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: FT NON -POTABLE: FT
BUILDING FOUNDATIONS: 5 FT
SITE SUBJECT TO FREQUENT FLOODING?
10 YEAR FLOOD ELEVATION FOR SITE:
CATT_ nnnFTT.F T VVNMMATTM STTF. 1
PROPERTY LINES: 5 FT POTABLE WATER LINES: 28 FT
`[ ]YES [X]NO 10 YEAR FLOODING? [ ]YES [X]NO]
FT[ MSL / NGVD ] SITE ELEVATION: FT [ MSL / NGVD
USDA SOIL SERIES:Lawnwood sand
Munsell #/Color Texture
Depth
10YR4/2
Sand
OTo11
10YR 5/2
Sand
11 To 25
10YR 6/2
Sand
21 To 30
1 OYR 2/1
Spodic Material
30 To 46
10YR 4/3
Sand
46 To 72
QnTT. DROFTT.E TNFDRMATTON SITE 2
"USDA SOIL SERIES: Lawnwood sand
Munsell#/Color Texture
Depth
1 OYR 512
Sand
0 TO 19
10YR 6/2
Sand
16 To 20
1 OYR 211
Spod(c Material
20 To 34
7.5YR 3/3
Spodic Material
34 To 46 .
1 OYR 4/3
Sand
46 To 72
OBSERVED WATER TABLE: 46.00 INCHES [ ABOVE / BELOW ] EXISTING GRADE TYPE:
ESTIMATED WET SEASON WATER TABLE ELEVATION: 19 INCHES [ ABOVE / BEE]
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [X IYES [ ]NO
SOIL TEXTURE/LOADINGRATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: [ X ] TRENCH [
r REMARKS/ADDITIONAL CRITERIA
] BED
[ PERCHED / APPARENT ]
EXISTING GRADE
DEPTH: 19.00 INCHES
Sand/0.80 DEPTH OF EXCAVATION:
[ ] OTHER (SPECIFY)
SWIT determined using USDA WSS andsoilborings. 10YR 612 stripping In 10YR 512 matrix> 10%with diffuse boundaries starling
19" In S132. SB21" below BM. SB7 4" above BM
SITE EVALUATED BY:
Collier, Hunter (Title: Environmental Specialist Q (Florida Department of Health In St L
DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC
46 INCHES
DATE: 02/25/2020
Page 3 of 4
AP1467508 EID2038669 I v 1.0.2
�STATE OF FLORIDA
f DEPARTMENT OF HEALTH
p ONSITE SEWAGE TREATMENT AND DISPOSAL
SYSTEM
�`bv6`fi APPLICATION FOR CONSTRUCTION PERMIT
APPLICATION FOR:
PERM&T NO.
DATE PAID:
FEE PAID:
RECEIPT #:
New System [ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Repair [ ] Abandonment [ ] Temporary [ I
APPLICANT: St. Lucie Habitat for
AGENT:
MAILING ADDRESS:
TELEPHONE:
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. IT IS THE
APPLICANT'S RESPONSIBILITY TO PROVIDE DOCUMENTATION OF THE DATE THE LOT WAS CREATED OR
PLATTED (MM/DD/YY) IF REQUESTING CONSIDERATION OF STATUTORY GRANDFATHER PROVISIONS.
PROPERTY INFORMATION
LOT: 30 BLOCK: 61 SUBDIVISION: INDIAN RIVER ESTATES PLATTED: Y
PROPERTY ID #: 3402-609-0348-000-3 ZONING: R I/M OR EQUIVALENT: [ No ]
PROPERTY SIZE: .23 ACRES WATER SUPPLY: [ ] PRIVATE PUBLIC [ ]<=2000GPD [,(]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [ No ] DISTANCE TO SEWER: NA FT
PROPERTY ADDRESS: 5715 Palm Drive, Fort Pierce, FL
DIRECTIONS TO PROPERTY: FROM THE INTERSECTION OF US (FEDERAL HYW) AND EASY STREET, TRAVEL
EAST ON EASY STREET TO PALM DRIVE, TRAVEL NORTH ON PALM DRIVE, OVER BARTOW STREET, .17 MILE, 10T�t(
LOT ON THE WEST SIDE OF THE STREET
BUILDING INFORMATION
Unit Type of
No Establishment
1 SINGLE FAMILY
11
[ ,/ ] RESIDENTIAL [ ] COMMERCIAL
No. of Building Commercial/Institutional System Design
Bedrooms Area Sqft Table 1, Chapter 64E-6, FAC
3 1709 300 gallons per day
4
[ ] Floor/Equipment Drains [ ] Other (Specify)
SIGNATURE: DATE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
Page 1 of 4
APPLICANT:
Property owner's full name.
AGENT:
Property owner's legally authorized representative. —
TELEPHONE: '
Telephone number for applicant or agent. '
MAILING ADDRESS:
P.O. box or street, city, state and zip code mailing address for applicant or agent.
LOT, BLOCK,
Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in a
SUBDIVISION:
recorded subdivision, a copy of the lot legal description or deed must be attached.
DATE OF SUBDIVISION:
Official date of subdivision recorded in county plat books (month/day/year) or date lot
originally recorded. Dividing an approved lot into two or more parcels for the purpose of
conveying ownership shall be considered a subdivision of the lot.
PROPERTY ID#:
27 character number for property. CHID may require property appraiser ID # or
section/township/range/parcel number.
ZONING:
Specify zoning and whether or not property is in I/M zoning or equivalent usage.
PROPERTY SIZE:
Net usable area of property In acres (square footage divided by 43,560 square feet)
exclusive of all paved areas and prepared road beds within public rights -of way or
easements and exclusive of streams, lakes, normally wet drainage ditches, marshes, or
other such bodies of water. Contiguous unpaved and non -compacted road rights -of -way
and easements with no subsurface obstructions may be included in calculating lot area.
WATER SUPPLY:
Check private or public <= 2000 gallons per day or public > 2000 gallons per day.
SEWER AVAILABILITY:
Is sewer available as per 381.0065, Florida Statutes, and distance to sewer in feet.
PROPERTY ADDRESS:
Street address for property. For lots without an assigned street address, indicate street
or road and locale in county.
DIRECTIONS:
Provide detailed instructions to lot or attach an area map showing lot location.
BUILDING INFORMATION:
Check residential or commercial.
TYPE ESTABLISHMENT:
List type of establishment from Table II, Chapter 64E-6, FAC. Examples: single family,
single wide mobile home, restaurant, doctor's office.
NO. BEDROOMS:
Count all rooms designed primarily for sleeping and those areas expected to routinely
provide sleeping accommodations for occupants.
BUILDING AREA:
Total square footage of enclosed habitable area of dwelling unit, excluding garage,
carport, exterior storage shed, or open or fully screened patios or decks. Based on
outside measurements for each story of structure.
BUSINESS ACTIVITY:
For commercial/institutional applications only. List number of employees, shifts, and
hours of operation, or other information required by Table 11, Chapter 64E-6, FAC.
FIXTURES:
Mark Floor/Equipment Drains or Others and specify item or "NA" if not applicable.
SIGNATURE / DATE:
Signature of applicant or agent. Date application submitted to the CHID with appropriate
fees and attachments.
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences or
buildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope of
property, any existing or proposed wells, drainage features, filled areas, obstructed areas, and surface water. Location of
wells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent property, if
the features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residences, a floor
plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, a floor
plan showing the square footage of the establishment, all plumbing drains and fixture types, and other features necessary
to determine composition and quantity of wastewater,
r 4 STATE OF FLORIDA PERMIT#.
r DEPARTMENT OF HEALTH '
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: St. Lucie Habitat for Humanity AGENT:
LOT:30 BLOCK:61 SU13DIVISION:INDIANRIVER ESTATES
PROPERTY ID # : 3402-609-0348-000-3 [ Tax ID Number ]
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MUST PROVIDE REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE
PLAN:
I✓] YES [ ]
NO NET USABLE AREA AVAILABLE: 0.02
ACRES
TOTAL ESTIMATED. SEWAGE FLOW:
300
GALLONS
PER DAY [RESIDENCES-TABLEI
]
AUTHORIZED SEWAGE FLOW.:
575
GALLONS
PER DAY I2500 GPD/ACRE
]
UNOBSTRUCTED AREA AVAILABLE:
946
SQFT
UNOBSTRUCTED AREA REQUIRED: 750
SQFT
BENCHMARK/REFERENCE POINT LOCATION
ELEVATION OF PROPOSED SYSTEM SITE
[INCHES I [ABOVE ]
POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES
SURFACE WATER: N/A FT DITCHES/SWALES:15 FT NORMALLY WET? [ ] YES ]✓] NO
WELLS: PUBLIC: NA FT LIMITED USE: NA I FT PRIVATE: NA FT NON -POTABLE: NA FT
BUILDING FOUNDATIONS:5 FT PROPERTY LINES:5 FT POTABLE WATER LINES: 25 FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [✓] NO 10 YEAR FLOODING? ] YES ]✓] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: 17.36 FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1
MUNSELL #/COLOR TEXTURE DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
USDA SOIL SERIES:
TEXTURE
DEPTH
TO
TO
TO
TO
TO
TO
TO
mo
rV
OBSERVED WATER TABLE: INCHES [ABOVE/BELOW '] EXISTING GRADE. TYPE:[ PERCHED /APPARENT ]
ESTIMATED WET SEASON WATER TABLE ELEVATION: INCHES [.ABOVE/BELOW ] EXISTING GRADE
HIGH WATER TABLE VEGETATION: [ I YES [ I NO MOTTLING: ( ] YES I I NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:
DRAINFIELD CONFIGURATION: ( ] TRENCH [ ]
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY
DH 4015, 08/09 (Obsoletes previous editions which
_ DEPTH OF EXCAVATION
OTHER (SPECIFY)
)rpora ed n64-6.001, FAC
O(/�/
INCHES
Page 3 of 4
INSTRUCTIONS:
`y
PERMIT #: Pem`dt tracking number assigned by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK,SUBDMSION: Lot, block, and subdivision for lot.
PROPERTY ID#: 27 character number for property (property appraiser ID # or section/township/range/parcel number).
PROPERTY SIZE: Check if property size at site conforms to submitted site plan. Record net usable area available - lot area exclusive of all paved areas
and prepared road beds within public rights -of -way or easements and exclusive of streams, lakes, normally wet drainage ditches,
marshes, or other such bodies of water.
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table 1 (residential) or Table 2 (non-residential), Chapter 64E-6,
FAC. Record the authorized sewage flow for the lot based on net usable area and water supply (1500 gallons per day per acre for
private water supplies and 2500 gallons per day per acre for public water supplies). If authorized sewage flow does not equal or
exceed the estimated sewage flow, the application must be denied.
UNOBSTRUCTED AREA:
Record the square feet of unobstructed arm available and the amount required. Unobstructed area must be at least 2 times as large
as the dminfield absorption area and at least 75 percent of the unobstructed area must meet minimum setbacks in Chapter 64E-6,
FAC. The unobstructed area most be contiguous to the dramfield.
BENCHMARK INFORMATION:
Record the location of the benchmark. If using a surveyor's benchmark record the actual elevation. Record the elevation of the
proposed system site in relation (above in below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be met to all listed features. Actual measurements must be recorded or "NA" for non
applicable features. Features on site plan or within 75 feet of the applicant lot most be measured. The location of any public
drinking well within 200 feet of the applicant's lot must also be verified.
FLOOD INFORMATION:
Record information on lot's subject to flooding. For lots subject to flooding record 10 year flood elevation for site and actual site
elevation.
SOIL PROFILE INFORMATION:
Two soil profiles within the proposed absorption area to a minimum depth of 6 feet or refusal are required. Soil identification will
use USDA Soil Classification methodology (Munsell colors and USDA soil textures). Refusals must be clearly documented.
Provide USDA soil series if available, record "UNK" if the series cannot be determined.
WATER TABLE:
Record the depth of the observed water table at the time of the evaluation. Mark "perched" or "apparent" as appropriate. Record the
estimated wet season water table elevation based on site evaluation, USDA soil maps, and historical information. Indicate if there is
high water table vegetation present. Indicate if mottling is present and depth.
SOIL TEXTURE: Record soil texture or loading rate for system sizing.
DEPTH OF EXCAVATION: If applicable record depth of excavation required. Record "NA" if not applicable.
DRAINFIELD CONFIGURATION: Check dminfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. Dosing required.
STYE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must scal all documentation submitted.
ELEVATION WORKSHEET
ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK
SITE I SITE 2 SITE 3
[+] SHOT
H.I. H.I. H.I.
ILL
[-] SHOT [+ SHOT [-] SHOT