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

What Is Form DH3143?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 1994;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DH3143 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

ADVERTISEMENT
ADVERTISEMENT

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

675 times
Rate (4.5 / 5) 34 votes
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