HomeMy WebLinkAboutAPPLICATION FOR ONSITE SEWAGE DISPOSAL SYSTEMT"E"F STATE OF FLORIDA
EPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
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CATION FOR ONSITE SEWAGE DISPOSAL SYSTEM CONSTRUC 1N P R IT
�° �,�•C�i II ,�� ^n� t�Co Ar C
Applica t X�C Permit Application Number
------- .I --. ------ �..---------------------- PART 111 SITE EVALUATION INFORMATION ....................................................
1_ Lot size appears to be as indicated on site plan: Yes No-
ll
CANNED
2. Anticipated sewage. flow from Part I GPD Authorized sewage flow GPD
h
l -�
3. B i nchmark• 1 cation ��(� +"C ul P I I f
i
:4. Existing
elev .tion (at time of site evaluation) of.the proposed system site in relation to the benchmark
is U ' inches above/below the benchmark.
-��4
5. Proposed system distance to:•Surface water � � : feet feet feet; Private potable
t �_
wells- feet feet feet; Community public wells C2: Meet feet;
{
O her public- ells is feet - feet; Non -potable wells (� feet feet;
6.. •Unobstructed area available for system installation . �`'`'�t2 ft2 ft9 '
i -
7.. Is lot subject Ito frequent flooding? Yes No, 10 year flood? Yes No
If �e�t to i 10 year fto0d irtdibat&. (a) the 10 year flood elevation in the area `-.feet ,MSL
{b) prope`rfy 'leNid ion at proposed system location feet MSL.
_Qn11 Ps1nFll F - SOIIAPLF SITF 1 SOIL PROFILE - SAMPLE SITE 2
CO OR
TEXTURE
DEPTH
I
0„ to
�
sand
12" to�„
t0 r (7„
�k
(
to �/�„
14--pio
to L� „
COLOR
TEXTURE
DEPTH
0„ to
„ to
„ to
„ to
" to
„ to
(�J. l (oG
USDI Soil Serie N9eV�Known) USDA Soil Series Name (if Known)
USDA Soil textute classification on which drainfield size should be based
Wat r table at. time of evaluation Estimated wet season water table inches
inches- be,existing grade below/above existing grade
Type water table: / Is mottling found in the soil? Yes No
Perched Apparent At what depth? Inches Inches
Are vigetative sJecies indicative / For property with contiguous ditches:
of high water table? Yes No Depth of ditches inches inches i
Depth of water in ditches inches inches
Other, findings:
.'r�.� .gam:1 i1. I' {�✓.' • �"^'• %1
Date of Site Evaluation Evaluator's Signature
(Includesea(If perf mod byP.P.)
HFIS—Hj Form 4015, Feb (Obsoletes previous editions which may not be used)
(StockiJlumber" 5744.003V,015.1) + Page 3 of 3