HomeMy WebLinkAboutSewage Evaluation, System SpecificationsSTATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT:
-r.
LOT:A FiCD BLOCK:
PROPERTY ID #:
AGENT:
SUBDIVISION:
PERMIT #
[Section/Township/Range/Parcel•No. or Tax ID Number]
TO BE COMPLETED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE -REGISTRATION NUMBER AND SIGN AND SEAL EACH PAGE OF SUBMITTAL. COMPLETE ALL ITEMS.
PROPERTY SIZE CONFORMS TO SITE PLAN: YES [ ] NO NET USABLE AREA AVAILABLE: �••'(? ACRES
TOTAL ESTIMATED SEWAGE FLOW: -:>00 % - GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: (55 GALLONS PER DAY '[1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: UNOBSTRUCTED AREA REQUIRED: 3 ®.4Jo SQFT
e "K
BENCHMARK/REFERENCE. POINT LOCATION: _ir- k-c- ( .,.a ,000,C)n' , .,_,su(4120�
ELEVATION OF PROPOSED SYSTEM SITE IS [INCHES/9OVE,BELOW] BENCHMARK/EFERENCE POINT
THE.MINIMUM'SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATERS E t" FT DITCHES/SWALES: 1-�5 k FT NORMALLY Wbt? [ ] YES [+ NO
WELLS: PUBLIC: FT LIMITED USE: 100 } FT PRIVATE: �.? $ FT NON -POTABLE: e�O $ FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: �� FT. POTABLE WATER LINES: -- FT
SITE SUBJECT TO FREQUENT FLOODING:'•-[ j YES NO 10.YEAR FLOODING? [ ] YES.. NO
10 YEAR FLOOD ?S
ELEVATION FOR"IFE MS!L,/NGVD SI.T7E EI? VATION: FT MSL NGVD
SOIL PROFILE INFORMATION SITE 1 SOIL PRC(FILEf INFORMATION SAE '2"'
Munsell #/Color Texture Depth
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USDA SOIL SERIES:
Munsell #..Color Texture Depth
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USDA SOIL SERIES:
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: [ ] YES [ ] NO MOTTLING: [ ] YES
[ ] NO DEPTH:: INCHES
SOIL TEXTURE/LOADIN.G RATE FOR SYSTEM SIZING: DEPTH OF EXCAVATION: INCHES
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DRAINFIELD CONFIGURATION: [ ] TRENCH [ ] BED [ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:. _ DATE: G'
OH 4015, T019fi (Replaeas HRS-H Form 4015 [page 3),.wjtlFh may. ed�: Page 3 Of
(Stock Number: 6744-003-4015-1) °' -> 13