HomeMy WebLinkAboutD O H PAPERWORK'e STATE OF FLORIDA i "> PERMIT if c _
DEPARTMENT OF HEALTH O
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATpIgON AND SYSTEM SPECIFICATIONS St Lucie COU11t/
oon wa� �®� •. M ��Fs 7'0 ���®�
APPLICANT: / . i eL� �y � e� k h' AGENT: e7TelN &.4j _,'
LOT:luivil' BLOCK: ,[�-[ SUBDIVISION: 4pec1.1_ WLIP, Ft�-,a.A¢ 1-1 t4 rr
PROPERTYiID is -�-- [Section/Township/Range/Parcel No. or Tex ID Number]
r
TO,aE 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.: W 'YES [ ] NO NET USABLE AREA AVAILABLE: 41�`9 ACRES
TOTAL ESTIMATED SEWAGE FLOW: 4-i0e.7 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZE�D SEWAGE FLOW: ogpo GALLONS -PER DAY ['1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
yam, 1 Q v Q y ,."+f?!i' L; 670
BEHCHMARR/REFERENCE POINT LOCATION,: 1w.) Pr:tLI iL, pO)..� N C- C.YAmy. F.IT... a76.% f!Bn GF..,=
ELEVATION OF PROPOSEDSYSTEM SITE ISM [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE, POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM. THE PROPOSED 'SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: ./ FT DITCHES/SWALES: t�l /� FT NORMALLY WET? [ ] YES [ t�]✓}:0
WELLS:. PUBLIC: FT LIMITED USE: �, PT PRIVATE: 'I FT MOM -POTABLES n4 FT
BUILDING,FOUNDATIONS: 19 FT PROPE INES: 1 FT POTABLE WATER .LINES: (f.3 FT
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 SOIL PROFILE INFORMATION SITE
Munselll'#/Color Texture Depth
to
to
to
to
to
I to
to
I� to
to
USDA SOIL SERIES:
i!
OBSERVED WATER TABLE: INCHES
ESTIMATED WET .SEASON WATER TABLE EL
HIGH WATER TABLE VEGETATION [ ]rYi
SOIL TE%TUBE/LOADING RATE FO;t SYSTEI
'DRAINFIELD CONFIGURATION: ] T_REI
REMAR%SJADDITIONAL CRITERI,A:
Munsell #/Color Texture Depth
to
to
to
�� o t
Ink to
I to
[ABOVE —/ BELOW] STING GRADE. TYPE: [PERCHED / APPARENT)
VAfi N INCHES [ ABOVE / BELOW ] EXISTING GRADE..
[ ]-`NOS - OTTLINO:. [ ] YES [ ] NO DEPTH: INCHES.
I SIZING DEPTH OF EXCAVATION: INCHES
CH „ ] BrEIi - [ ] OTHER SPECIFY)
I
�� F,:;,prxtt �•,
SITE EVALUATED BY: —7 1. t7ij:Pr*V*W •,;)' s'"`
Page ~3 of •3
DHA015„ 10188 (ReplaceHRS-RForm.4015 (Pe0e.31 which may be used) • - -
(Stock Number: e574400340154 );. liz
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n a Y _ a a a a •o
INSTRUCTIONS:
PERMIT NUMBER:
APPLICANT:
AGENT:
LOT, BLOCK, SUBDIVISION:
PROPERTY ID NUMBER:'
PROPERTY SIZE:
Permit: tracking number by Cmlmy Health Department.
Property owner's full name.,
Property owner's legally authorized representative.
Lot, block, and subdivision for lot.
27 character number for property (property appraiser ID number
Check if.property at site conforms to submitted site plan. Record net usable area available -
all paved areas and prepared road beds within public rights -of -way or easements and exclusi,
normally web drainage ditches, marshes, or other such bodies of water.
number).
rea exclusive of
streams, takes,
SEWAGE FLOW: Record the estimated sewage flow for the establishment from Table I (residence) or Table 2 (non-residential),
Chapter IOD-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 watet 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 unobstructedareaavailable and the amount required. Unobstructed A.Sea must be at
least 2 times as large as the. drainfield absorption area and at least 75.percent of the unobstructedarea mustmeet
minimum setbacks in Chapter I0D-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 elev lion. Record the
elevation of the proposed system sitein relation (above or below) to the be:easements
hmark.
MINIMUM SETBACKS: Record minimum setbacks which can be meet to all listed features: Actual rmust a recorded or
"NA" for nonapplicable features. Features on site plan or within 75 feet of the applicant lot mutt be measured.
The location of any public drinking well within 200 feet of the applicant's lot must also be verted.
FLOOD INFORMATION: Record information on lot's subject to flooding. For lots subject to flooding. record 10 year flo �d elevation for
site and actual site elevation.
SOIL PROFILE INFORMATION: Two soil profiles within the proposed absorption area to a minimumdep[h of 6 feet or refusal ai 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. III
WATER TABLE: Record the depth of the observed water table at the time of the evaluation. Mark "perched" or'
, pparent" as
appropriate. Record the estimated wet season water table elevation based on site evaluation, US DA soil maps,
_and historical information. Indicate if there is high water table vegetation present. Indicate if i{jottling is present
and depth. !'I
SOD. TEXTURE:
DEPTH. OF EXCAVATION:
DRAINFIELD CONFIGURATION:
ADDITIONAL CRITERIA:
SITE EVALUATED BY:
ELEVATION WORKSHEET
Record soil texture or loading rate for system sizing.
If applicable record depth -of excavation required. Record "NA" if not applicable.
Check drainfield configuration required.. If other, specify type.
Record any additional remarks pertinent to site or installation. Ex. dosing required.
Signature of evaluator, title, and date of evaluation. Professional engineers must seal all
ELEVATION OF BENCHMARK / REFERENCES POINT IS'.
BENCHMARK SITE I SITE,2
(+ i SHOT H.I. H.I.
H.T. [ -I SHOT [ - I SHOT'
SITE 3
H.I.
[ - I SHOT
submitted.
er✓
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STATE OF FLORIDA,
DEPARTMENT'OF HEALTH
ONSITE. SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
PERMIT NO.
DATEPAIDS
FEE PAID:
RECEIPT #S - -
APPLICATION FOR:
] Now System [ ]' Existing System [ ] Holding Tank [ ] Innovative
p R®pair - [ ] Abandonment_ [ ] Temporary L ]
.APPLICANT: RA'2o(Z'S '�i,.]G.. - �`0rj
AGENT:�T
MAILING. ADDRESS: LeP lit t A T 4a -�In STREe-T e7Ty.¢1rl-T F--i,
TO BE COMPLETED BY APPLICANT OR :APPLICANT'S AUTHORISED AGENT. SYSTEMS MUST BE CONSTRUCTED
BY A.PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES. ~
PROPERTY INpQF,ORMATION. - -
LOTA0 {WU BLOCR: 41 1 SUBDIVISION:eM61,4 1,.UGICie PLAZA ON11'04i✓ PLATTED:10 10 114LZG-.
PROPERTY ID IS
ZONING: I/M OR EQUIVALENT: [ Y
PROPERY SIZES p. ACRES. WATER SUPPLY: K ] PRIVATE PUBLIC [ ].<-2000GPD ( '1>2000GPD
19 SEWER. AVAILABLE AS PER 381.0065, PS? [`Y /�] DISTANCE TO SEWERS !T
PROPERTY ADDRESS: J, .j (--J -r Dj � I Fi F3 (.�1b , �, -q .�®T: 4�1 t� z� (G -� .
DIRECTIONS TO PROPERTYs ��,� (sOLv'CT {O�l tAA
d
BUILDING INFORMATION
Unit Type of
No Establishment
2
3
4 .
N ] RESIDENTIAL
No. of Building Cox
Bedrooms Area Sqft Tab
[ ]. COMMERCIAL
tial/Institutional System Design
1, Chapter 64E-6, PAC
(Specify) 01'7 POS AL-
_ SIGNATURE.: DATE: �'�d/40% -
1 v
DH 4015, 10/97 — P29e 1 (Previous editions may be used) page 1 of 3
Stock `Number: 5744-001'-4015-1
APPLICATION FOR: Check ty
pe of permit, F7 "Other :pacify type In blank.
APPLICANT: Property owner's full name. j
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 ag nt.
LOT, BLOCK, Lot, block, and subdivision for lot (recorded or unrecorded subdivision). if to I 'a not in a
SUBDIVISION: recorded subdivision, a copy of the lot legal description or deed must be a'trehed.
DATE, OF SUBDIVISION:
Official date of subdivision recorded In county plat books (month/day/year) o�! ate lot
originally recorded. Dividing an approved lot Into two or more parcels for the arpose of
conveying ownership shall be considered a subdivision of the lot.
II
PROPERTY ID#:
27 character number for property. CHO may require property appraiser ID V r
section/township/range/parcel number.
ZONING:
i
Specify zoning and whether or not property is in I/M zoning or equivalent usa e.
PROPERTY SIZE:
Net usable area of property In acres (square footage divided by 43,580 squaree I 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 r1q, ts-of-way
and easements with no subsurface obstructions may be included in calculatin lot area.
WATER SUPPLY:
Cheer private or public <= 2000 gallons per day or public > 2000 d
gallons per y.
SEWER AVAILABILITY
Is sewer available as per 381.0065, Florida Statutes, and distance to sewer frill eet.
PROPERTY ADDRESS:
Street address for property. For lots without an assigned street address, ind,clal to street
or road and locale in county. N
DIRECTIONS: Provide detailed instructions to lot or attach an area map showing lot location. ,
BUILDING INFORMATION: Check residential or commercial.
i
TYPE ESTABLISHMENT: List type of establishment from Table II, Chapter 10D-8, FAC. Examples: singl family,
single wide mobile home, restaurant, dolor's office. Q
NO. BEDROOMS: Count all rooms designed primarily for sleeping and those areas expected to routinel
provide sleeping accommodations for occupants.
I
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.
BUSINESSACTIVITY. For commerciaUnstitutional applications only. Last number of employees, shifts; and
hours of operation, or other Information required by Table 11. Chapter f OD-e, F ,
FIXTURES: Mark Floor/Equipment Drains or Others and specify item or "NA" if not appiicabII4I
SIGNATURE /DATE: Signature of applicant or agent. Date application submitted to the OHD with app'opr
fees and attachments. J;
ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of resldences`ior
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. Lo' ion of
wells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent pro ' rty, if
the features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residencesi') a floor
plan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishment, 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. 11
STATE OF FLORIDA
DEPARTMENT OF HEALTF
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
CONSTRUCTION PERMIT
CONSTRUCTION PERMIT FOR:
['X ]New System [ ]Existing System
[ •]Repair [ ]Abandonment
APPLICANT:,Shell Razor's Inc.
[ ]Holding Tank {
[ ]Temporary [
AGENT:STEPHEN BROWN
C. ZAX #: 56-SF-09182
D_,.__ PAID:
FEE PAID : $
RECEIPT
OSTDSNBR : 07-00043 -N
Innovative Other
PROPERTY STREET ADDRESS: W Dixie Blvd Fort Pierce FL 34946
LOT:. 16-18 BLOCK: 41 SUBDIVISION: San Lucie Plaza
[Section/Township/Range/Parcel No.]
PROPERTY ID #: 29-34S-40E- [OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF CHAPTER 64E-6,FAC
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY PERFORMANCE FOR ANY SPECIFIC TIME
PERIOD. ANY CHANGE IN MATERIAL FACTS WHICH SERVED AS A BASIS FOR ISSUANCE OF THIS PERMIT,
REQUIRE THE APPLICANTTO.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 PROPERTY DEVELOPMENT.
SYSTEM DESIGN AND SPECIFICATIONS
T [ 1050 ]Gallons SEPTIC TANK MULTI-CHAMBERED/IN SERIES: [Y ]
A [ 0 ]Gallons MULTI-CHAMBERED/IN SERIES:. [Y ]
N [ 0 ]GALLONS GREASE INTERCEPTOR CAPACITY
K [ 0 ]GALLONS DOSING TANK CAPACITY [ 0 ]GALLONS
,1 @ [0 ]DOSES PER 24 HRS # PU PS[
D [ 615 j]SQUARE 'FEET PRIMARY DRAINFIELD SYSTEM 5 �r✓` l� ��,`G��T00
R [ 0 ]SQUARE FEET SYSTEM {{{{V/
A TYPE SYSTEM: [ N ]STANDARD [ Y ]FILLED [ N ]MOUND [ N ]
I CONFIGURATION: [ N ]TRENCH [ Y ]BED [ N )
N
F LOCATION TO BENCHMARK: Nail In Power Pole Located Near NE Property Corner
C
I ELEVATION OF PROPOSED SYSTEM SITE [ ]
[ INCHES
] [ ABOVE] BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE [ 1.0 ]
[ INCHES
] [ BELOW] BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED:[ 14.0 ]INCHES EXCAVATION
REQUIRED: [
84.0 ] INCHES
OTHER REMARKS:
The licensed contractor installing the system is responsible for installing the minimum
category of tank in accordance with s. 64E-6.013(3)(f), FAC.
Home stubout invert to be 11 inches above benchmark.
Excavate 531xl4'x7' deep.
SPECIFICATIONS BY: POLISSKY, JODI
APPROVED BY: Polissky, Jodi
TITLE:
TITLE: Environmental Spec St. Lucie CHD
DATE ISSUED: 3/7/07
DH 4016, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-001-4016-0) 1ostds_cons_4016-11
EXPIRATION DATE: 9/7/08
Page 1 of 2
_APPLICATION FORS
(;y ] New System
(/ ] Repair
APPLICANTt s
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
APPLICATION FOR CONSTRUCTION PERMIT
`' ,(", ,'
P.ERNIT NO.I
DATE PAID: �2
FEE PAIDs L
RECEIPT /:
[ ] Existing System [ ] Holding Tank [ ] Innovative
[ ] Abandonment [ ] Temporary [ ]
AGENT:Pt+e,.4
-L F-r���-
I �
TELEPHONE:64 tF
NAILING ADDRESS:
fe tf-A (:-,-A4:7T CJ "Ll
ST-ReleT
4TUALzT rL 3499 14
xaaaaxaxxxx—xxaxaaaxxaaxxmxaa�aaxxaaszaazaaaaavaaauzsaaaaaxxxxxxax�xaxxrx--aa--x�--x
TO BE COMPLETED BY APPLICANT OR APPLICANT'S AUTHORIZED AGENT. SYSTEMS RUST BE
BY A PERSON LICENSED PURSUANT TO 489.105(3)(m) OR 489.552, FLORIDA STATUTES.
a xxx�xaaaaxaxxxxaxaxaxaxxsaasxaxaaazaaaazaaaaaxzaaaaaa^--�•+•-xavxxamaaxxxxxx�aaaxax
PROPERTY INFORMATION LOT: jtP t ibRI.00ilt 41 SUBDIVISION: SAi,4 LUG( PbAM Ail-046PLATTEDt 1! l0 M2.T
PROPERTY ID 1:
ZONINGt
I/N OR EQUIVALENTS
[ Y / 7'J
PROPERY SIZEi a -7 ACRES WATER SUPPLY:
[)(] PRIVATE
PUBLIC [ ]<=2000GPD [
]>2000GPD
IS SEWER AVAILABLE AS PER 381.0065, FS? [
Y /�
DISTANCE TO SEWERS
FT
PROPERTY ADDRESS: W G,1�7-r/ p['6 t G
P)i -4b
� PLOR.C:(5
DIRECTIONS TO PROPERTY: '- Gc-- LQ'i«T
IQ61 tAAP
BUILDING
unit Type of
No Establishment
No. of Building
Bedrooms Area Sqft
1 GitiaCTL� '�/4N1tlti' 2
.-2
3
4
[ ] COMMERCIAL
Cial/Institutional System Design
1, Chaptar 64E-6, PAC
[ j Floor/Equipment Dra
[ Oth (Specify)
b LS PO S Ali
SIGNATURE t 4T G
i3 W rj
DATE:
'Z l v
/ +y
f !
DH 4015, 10/97 - Page 1 (Previous editions may be used) page 1 of 3
Stock Number: 5744-001-4015-1
_4. STATE OF FLORIDA
`. DEPARTMENT OF HEALTF
ONSITE SEWAGE DISPOSAL SYSTEM
'w SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT: Shell Razor's Inc.
AGENT: STEPHEN BROWN
CENTRAX #: 56-SF-09182
OSTDSNBR : 07-00043-N
LOT: 16-18 BLOCK: 41 SUBDIVISION: San Lucie Plaza ID#: 29-34S-40E-
TO BE COMPLETED BY ENGINEER,
MUST PROVIDE REGISTRATION NUMBER
HEALTH DEPARTMENT EMPLOYEE,
AND SIGN AND SFAi RACH PAGE
OR OTHER QUALIFIED PERSON. ENGINEER'S
OF SURMTTTA COMPLFTR ALL ITEMS -
PROPERTY SIZE CONFORMS TO SITE PLAN: [X]YES [ ]NO
NET
USABLE AREA AVAILABLE: 0.47 ACRES
TOTAL ESTIMATED SEWAGE FLOW:
400 GALLONS
PER DAY
[64E-6, TABLE 11
AUTHORIZED SEWAGE FLOW:
705 GALLONS
PER DAY
[1500GPD/ACRE OR 2500GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE:
1700 SQFT
UNOBSTRUCTED AREA REQUIRED: 1143 SQFT
BENCHMARK/REFERENCE POINT LOCATION: Nail In Power Pole Located Near NE Property Corner
ELEVATION OF PROPOSED SYSTEM SITE IS 3.00 [ INCHES ] [ ABOVE ]BENCHMARK/REFERENCE 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 [ X NO
WELLS: PUBLIC: N/A FT LIMITED USE: N/A FT PRIVATE: 75 FT NON -POTABLE: N/A FT
BUILDING FOUNDATIONS: 5 FT PROPERTY LINES: 11 FT POTABLE WATER LINES: N/A FT
SITE SUBJECT TO FREQUENT FLOODING: [ ]YES [ X ]NO 10 YEAR FLOODING? [ ]YES [ X ]NO
10 YEAR FLOOD ELEVATION FOR SITE: 0 FT NGVD SITE ELEVATION: 0 FT NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell I#/Color Texture Depth
10VR-S/9-G RN Wino RnnA 0 to q
10YR-7/1-T. rV Fino RnnA A to 19
1 OVR-5/11-QV Fine Rand 19 tog0
1 OVR-9/9-V n RN flrnanin Rnil q0 t0 qR
10VR-9/1-RK Rareipan AA to R9
10VR-9IT-RK Rofnaal 59 to 79
to
to
USDA SOIL SERIES: 29 Pendarvis Sa
SOIL PROFILE INFORMATION SITE 2
Munsell #/Color Texture Depth
10VR-9/9-F RN Fino Rand () to R
1 DVR-7/1 -T. ry Fino Rand F to 1 R
I 0VR-S/1-rW Wino RnnA 1R to q0
10VR-9/9-V n RN nrganin Rni1 q0 to 40
1OYR-2/1-BK Rardpan 40 to r,4
10VR-9/1-RK RofnQal 1;4 to
to
to
USDA SOIL SERIES: 29Pendarvis Sa
OBSERVED WATER TABLE: 72.00 INCHES [ BELOW ] EXISTING GRADE TYPE: [ APPARENT ]
ESTIMATED�WET SEASON WATER TABLE ELEVATION:28.00 INCHES [ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: [ ]YES [X]NO MOTTLING: [ ]YES [X]NO DEPTH: 0.0 INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:Fine Sand/0.70 DEPTH OF EXCAVATION:84.0 INCHES
DRAINF.IELD CONFIGURATION: [ ]TRENCH [ X ]BED [ ]OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
Estimated WSWT determined from USDA Soil Conservation Svc soil survey of SLC S existing
BDF elevations of surrounding properties.
SITE EVALUATED BY: JODI POLISSKY DATE: 3/6/07
4
DH 4015, 03/97 (Obsoletes previous editions which may not be used)
(Stock Number: 5744-003-4015-1) (ostds_eval_4015-3) Page 3 of 3
-__ ,4, I
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATI
APPLICANT:. � � ALA- �ZA-2- c;P, ej ( Ir► ei
PERMIT /
AGENT: '�rl EF'H &IJ'". e7ROU-)L i
LOT: [u ` BLOCK: SUBDIVISION: 706CN. 1�,AyA L`t-4C
PROPERTY ID j: [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 SI2E CONFORMS TO SITE PLAN: 1gl YES [ ] NO NET USABLE AREA AVAILABLE: Os. ACRES
TOTAL ESTIMATED SEWAGE FLOW: 4'I�B7 GALLONS PER DAY [RESIDENCES -TABLE 1 / OTHER -TABLE 2]
AUTHORIZED SEWAGE FLOW: 'Vera GALLONS PER DAY [1500 GPD/ACRE OR 2500 GPD/ACRE]
UNOBSTRUCTED AREA AVAILABLE: SQFT UNOBSTRUCTED AREA REQUIRED: SQFT
t0Ou0Q /kG�7UmCo
BENCHMARK/REFERENCE POINT LOCATION: Fy� &-t&26 Z POUG DJ E
p Gv1��.eTL�r�1� Fr-+;vP�zr-1�
ELEVATION OF PROPOSED SYSTEM SITE IS 'Z_ [INCHES/FT] [ABOVE/BELOW] BENCHMARK REFERENCE POINT
THE MINIMUM SETBACK WHICH CAN BE MAINTAINED FROM THE PR POSED SYSTEM TO THE FOLLOWING FEATURES:
SURFACE WATER: µ LA FT DITCHES/SWALES: )`( FT NORMALLY WET? [ ] YES ['I.KNO
WELLS: PUBLIC: 14Z FT LIMITED USE: 7 FT PRIVATE: "r FT NON -POTABLE: � FT
BUILDING FOUNDATI NS: `j FT PROPE TY LINES: S FT' POTABLE WATER LINES: [U FT
SITE SUBJECT TO FREQUENT FLOODING: [ ] YES [ ] NO 10 YEAR FLOODING? [ j YES [ ] NO
10 YEAR FLOOD ELEVATION FOR SITE: FT MSL/NGVD SITE ELEVATION: FT MSL/NGVD
SOIL PROFILE INFORMATION SITE 1
Munsell k/Color Texture Depth
to
to
to
to
to
to
to
to
to
USDA SOIL SERIES:
SOIL PROFILE INFORMATION SITE 2
Munsell f/Color Texture Depth
to
to
to
to
to
to
to
to
USDA SOIL SERIES:
to
OBSERVED WATER TABLE: INCHES [ABO BELOW] EXISTING GRADE. TYPE: [PERCHED / APPARENT]
ESTIMATED WET SEASON WATER TABLE EL ION: INCHES [ ABOVE ./ BELOW ] EXISTING GRADE.
HIGH WATER TABLE VEGETATION: ['] S ( ] NO MOTTLING: [ ] YES [ ] NO DEPTH: INCHES
SOIL TEXTURE/LOADING RATE FO,K SYSTEM SIZING:_
DRAINFIELD CONFIGURATION: ] TRENCH /[ ]
REMARKS/ADDITIONAL CRITERI :
SITE EVALUATED BY:
DEPTH OF EXCAVATION: INCHES
[ ] OTHER (SPECIFY)
DN 4015, IMS (Replaces NRS-M Form 4015 (Pepe 31 which may be used)
(Stock Number: 5744-003-4015.1)
Page 3 Of 3