HomeMy WebLinkAboutD O H SEWAGE DISPOSAL - SITE EVAL AND SYSTEM SPECS - 6-23-98STATE OF FLORIDA PERMIT # �d 03 9
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: .� ` / AGENT: P-S 1.
LOT: q BLOCK: / SUBDIVISION: '!
PROPERTY IDi,#: t [Section/Township/Range/Parcel No. or Tax ID Number]
TO BE COMPL9'TED BY ENGINEER, HEALTH UNIT EMPLOYEE, OR OTHER QUALIFIED PERSON. ENGINEER'S MUST
PROVIDE REGIISTRATION 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: GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
BENCHMARK/REFERENCE POINT LOCATION: 411, of 7�yy� e` 2, y� C% aa}f�/ O
ELEVATION OF PROPOSED SYSTEM SITE IS �p BELOW REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PROPOSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: FT DITCHES/SWALES: FT NORMALLY WET? [ ] YES [ ] NO
WELLS: PUBLIC: FT LIMITED USE: FT PRIVATE: FT NON -POTABLE: FT
BUILDING FOUNDATIONS: FT PROPERTY LINES: FT POTABLE WATER LINES: FT
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SITE SUBJECT; TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOODING? [ ] YES [ ]-NO.
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE; INFORMATION SITE 1 SOIL PROFILE INFORMATfbN SITE 2
Munsell #/Color Texture
Depth
IQ yA- FS
0
tog,
to2
to-3G
i- r V 0014-
36
to 41Z
L� - ? P-S
?..
to 'YK
q F's
'0
to ..S A'
/ /'�SS
tom
to
USDA SOIL SERIES:
Munsell #/Color
Texture
Depth
)o
fs
C2
to /y
S ! f .S
10
to -Z �
/ f.S
% E'
to 3!C
o � �+,p•c.
Ito
�fG
ti�?rs
M6
to S"Y
'C• y P_S
.STD
to 6 0)
41 -1
1rS
60
-to �6
:t Pj
G 6
tom
to
USDA SOIL SERIES:
OBSERVED WATER TABLE: /VO rhs?INCHES [ABOVE / BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE ELEVATION:
29 INCHES
[ ABOVE / BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [
] YES (vVNO
MOTTLING: [ ]
YES [Q----NO DEPTH: INCHES
i
SOIL TEXTURE%LOADING RATE FOR
SYSTEM SIZING:
fS.6
A
DEPTH OF EXCAVATION:p INCHES
DRAINFIELD CONFIGURATION: [
] TRENCH [ ,-]—,BED
[ ] OTHER
(SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
i
SITE EVALUATED BY* _.rs�t r DATE: Q '
Page 3 of 3
DH 4015, 10196 (Raplaces HRS-H Form 4015 [Page 31 which may be used)
(Stock Number: 5744-063-4015-1)
1
INSTRUCTIONS:
PERMIT NUMBER: Permit tracking number by County Health Department.
APPLICANT: Property owner's full name.
AGENT: Property owner's legally authorized representative.
LOT, BLOCK, SUBDIVISION:
Lot, block, and subdivision for lot.
PROPERTY ID NUMBER:
27 character number for property (property appraiser ID number or section/township/range/parcel number).
PROPERTY SIZE:
Check if property 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 (residence) or Table 2 (non-residential),
Chapter 1 OD-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 gpd 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 area available and the amount required. Unobstructed area must be at
least 2 times as large as the drainfield absorption area and at least 75 percent of the unobstructed area must meet
minimum setbacks in Chapter IOD-6, FAC. The unobstructed area must be contiguous.to the drainfield.
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 or below) to the benchmark.
MINIMUM SETBACKS:
Record minimum setbacks which can be meet to all listed features. Actual measurements must be recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot must 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 in is present
and depth.
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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 drainfield configuration required. If other, specify type.
ADDITIONAL CRITERIA: Record any additional remarks pertinent to site or installation. Ex. dosing required.
SITE EVALUATED BY: Signature of evaluator, title, and date of evaluation. Professional engineers must seal all documents submitted.
ELEVATION WORKSHEET
ELEVATION OF BENCHMARK / REFERENCE POINT IS:
BENCHMARK
SITE 1 SITE 2 SITE 3
[ + ] SHOT
H.I. H.I. H.I.
H.I.
[ - ] SHOT [ - ] SHOT [ - ] SHOT
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