HomeMy WebLinkAboutSeptic Inspection Form.,�
STATE OF FLORIDA PENT _. -- -
j�` DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
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APPLICANT: -
CONTRACTOR / AGENT:
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TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK. CONTRACTOR OR
OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPL=ABLE ITEMS'
COMPLETE TANK CERTIFICATION BE"OW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERT'FTFn
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EXI,.,STTIING TANK INFORMA^_TC'N
GALLONS SEPTIC TANK/GPD ATU LEGEND:_ _ MATERIAL:\6nUc AG_ _ BAFFLED:[Y /f'./
[ ] GALLONS SEPTIC TANK/GPD ATU LEGEND: _ MATERIAL: BAFFLED:[Y / NI
[ ] GALLONS GREASE INTERCEPTOR LEGEND: _ MATERIAL:
[ IiALLUN.S' DUblNli 'TANK LsulLhu: MA"i'l7.t(lAL: -. f l'uP"-l'J: i J
I CERTIFY THAT THE LISTED TANKS WERE P^MPED ON � ! Z'i ;rL O aY S�Ar� NCTe'S HAVE
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS FILL LEGEND j, ARE FREE OF OBSERVABLE
DE ^ R LEAKS, AND HAVE A [ SOLIDS DEFLECTION DEVICE / LET FILTER VI ] 'NSTAL'ED.
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EXISTING DRAINFIELD INFORMATION t�
[L400 I SQUARE FEET PRIMARY DRAINFIELD SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: _' l X 1
[ I SQUARE FEET SYSTEM NO. OF TRENCHES [ ] DIMENSIONS: X_
TYPE OF SYSTEM: fJCI STANDARD f 1 FILLED f 1 MOUND f 1
CONFIGURATION: [ ] TRENCH f 7 BED [ l —---�--- - - -- --- - -
DESIGN: [ ] HEADER [ D-BOX [YN, GRAVITY SYSTEM [ ] DOSED SYSTme - -
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE INCHES [ ABOVE / BELOW]
SYSTEM FAILURE AND REPAIR INFORMATION
SYSTEM INSTALLATION DATE TYPE OF WASTE [i47 DOMESTIC [ ] COMMERCIAL
GPD ESTIMATED SEWAGE FLOW BASED ON [ j METERED WATER X, TABLE Is 64E-60 FAC
SITE [ 1 DRAINAGE STRUCTURES [ ] POOL [ j PATIO / DECK [ j PARKING
CONDITIONS: [ J SLOPING PROPERTY [ ]
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DRAINAGE /
RUN OFF
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WATER TABLE
FAILURE [ ] SEWAGE ON GROUND
SYMPTOM: [ j PLUMBING BACKUP [
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] TANK [ ] D BOX/HEADER
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SUBMITTED BY: TITLE/LICENSEC&*# v,4or, yLO�I�Ir ✓gyp
DH 4015, 08 09 DATE jit-Il�
/ (Obcol tos previous ed:.tions which may not ba used)
Incorporated 64E-6.001, FAC Page 4 d