Form DH3143 "Innovative Onsite Sewage Treatment and Disposal System Temporary Permit Application" - Florida

Form DH3143 is a Florida Department of Health form also known as the "Innovative Onsite Sewage Treatment And Disposal System Temporary Permit Application". The latest edition of the form was released in January 1, 1994 and is available for digital filing.

Download a PDF version of the Form DH3143 down below or find it on Florida Department of Health Forms website.

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Download Form DH3143 "Innovative Onsite Sewage Treatment and Disposal System Temporary Permit Application" - Florida

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INNOVATIVE ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
TEMPORARY PERMIT APPLICATION
Applicant Name
Phone # (
)
(Last, First, M.I. or Business Name)
Fax # (
)
Applicant Mailing Address:
(Business name)
(Street Address or P.O. Box)
(City)
(State) (Zip)
1.
List name, type and model number of innovative system or product (Attach by addendum).
2.
Supply the following minimum information:
A)
Research and development studies;
B)
Results of previous testing;
C)
Design and installation criteria;
D)
Performance and reliability data;
E)
A disinterested third party certifier report, or a
Florida Registered Engineer report;
F)
Copy of system or product warranty.
3.
If the above information is not available or determined to be insufficient by the department and a temporary
permit is issued for further testing and monitoring then a fee in an amount not to exceed $25,000.00 as authorized
under section 381.0066, Florida Statutes, will be agreed upon prior to application approval. This fee covers the
department's cost associated with the performance evaluation of the innovative system or product.
Applicant signature or authorized representative of applicant, if applicant is other than an
individual:
Title:
Date:
DEPARTMENTAL USE ONLY
1)
Application Number:
2)
Application Received By:
Date:
3)
Reviewed By:
Date:
4)
Additional Information Requested ....................................... Y/N
Date:
Information Needed:
Application Complete .......................................................... Y/N
Date:
5)
Application Approved .................................................................
Date:
7)
Temporary Permit Issued ..................................................... Y/N
Date:
8)
Application Denied ................................................................
Date:
Reason for Denial:
Reviewed By:
Date:
Title:
DH Form 3143, 01/94 Incorporated: 64E-6.004, FAC
INNOVATIVE ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
TEMPORARY PERMIT APPLICATION
Applicant Name
Phone # (
)
(Last, First, M.I. or Business Name)
Fax # (
)
Applicant Mailing Address:
(Business name)
(Street Address or P.O. Box)
(City)
(State) (Zip)
1.
List name, type and model number of innovative system or product (Attach by addendum).
2.
Supply the following minimum information:
A)
Research and development studies;
B)
Results of previous testing;
C)
Design and installation criteria;
D)
Performance and reliability data;
E)
A disinterested third party certifier report, or a
Florida Registered Engineer report;
F)
Copy of system or product warranty.
3.
If the above information is not available or determined to be insufficient by the department and a temporary
permit is issued for further testing and monitoring then a fee in an amount not to exceed $25,000.00 as authorized
under section 381.0066, Florida Statutes, will be agreed upon prior to application approval. This fee covers the
department's cost associated with the performance evaluation of the innovative system or product.
Applicant signature or authorized representative of applicant, if applicant is other than an
individual:
Title:
Date:
DEPARTMENTAL USE ONLY
1)
Application Number:
2)
Application Received By:
Date:
3)
Reviewed By:
Date:
4)
Additional Information Requested ....................................... Y/N
Date:
Information Needed:
Application Complete .......................................................... Y/N
Date:
5)
Application Approved .................................................................
Date:
7)
Temporary Permit Issued ..................................................... Y/N
Date:
8)
Application Denied ................................................................
Date:
Reason for Denial:
Reviewed By:
Date:
Title:
DH Form 3143, 01/94 Incorporated: 64E-6.004, FAC
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