1
2STATE OF FLORIDA
PERMIT #.
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT:
AGENT:
LOT:
BLOCK:
SUBDIVISION:
PROPERTY ID #:
[Section/Township/Parcel No. or Tax ID Number]
Section/Township/Parcel No. or Tax ID Number
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MUST PROVIDE REGISTRATION 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-TABLE2]
RESIDENCES-TABLE 1/OTHER-TABLE 2
AUTHORIZED SEWAGE FLOW:
GALLONS PER DAY
[1500 GPD/ACRE OR 2500 GPD/ACRE]
1500 GPD/ACRE OR 2500 GPD/ACRE
UNOBSTRUCTED AREA AVAILABLE:
SQFT
UNOBSTRUCTED AREA REQUIRED:
SQFT
BENCHMARK/REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
[INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
INCHES / FT
ABOVE / BELOW
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
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 INFORMATION SITE 2
MUNSELL #/COLOR
TEXTURE
DEPTH
MUNSELL #/COLOR
TEXTURE
DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
USDA SOIL SERIES:
OBSERVED WATER TABLE:
INCHES
[ABOVE / BELOW] EXISTING GRADE. TYPE:[PERCHED / APPARENT]
ABOVE / BELOW
PERCHED / APPARENT
ESTIMATED WET SEASON WATER TABLE ELEVATION:
INCHES
[ABOVE / BELOW]
EXISTING GRADE
ABOVE / BELOW
HIGH WATER TABLE VEGETATION: [ ] YES
[ ] NO
MOTTLING: [ ] YES
[ ] NO
DEPTH:
INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:
DEPTH OF EXCAVATION:
INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH
[ ] BED
[ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
DATE:
Page 3 of 4
DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC
STATE OF FLORIDA
PERMIT #.
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SITE EVALUATION AND SYSTEM SPECIFICATIONS
APPLICANT:
AGENT:
LOT:
BLOCK:
SUBDIVISION:
PROPERTY ID #:
[Section/Township/Parcel No. or Tax ID Number]
Section/Township/Parcel No. or Tax ID Number
TO BE COMPLETED BY ENGINEER, HEALTH DEPARTMENT EMPLOYEE,OR OTHER QUALIFIED PERSON. ENGINEERS
MUST PROVIDE REGISTRATION 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-TABLE2]
RESIDENCES-TABLE 1/OTHER-TABLE 2
AUTHORIZED SEWAGE FLOW:
GALLONS PER DAY
[1500 GPD/ACRE OR 2500 GPD/ACRE]
1500 GPD/ACRE OR 2500 GPD/ACRE
UNOBSTRUCTED AREA AVAILABLE:
SQFT
UNOBSTRUCTED AREA REQUIRED:
SQFT
BENCHMARK/REFERENCE POINT LOCATION:
ELEVATION OF PROPOSED SYSTEM SITE IS
[INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
INCHES / FT
ABOVE / BELOW
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
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 INFORMATION SITE 2
MUNSELL #/COLOR
TEXTURE
DEPTH
MUNSELL #/COLOR
TEXTURE
DEPTH
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
USDA SOIL SERIES:
USDA SOIL SERIES:
OBSERVED WATER TABLE:
INCHES
[ABOVE / BELOW] EXISTING GRADE. TYPE:[PERCHED / APPARENT]
ABOVE / BELOW
PERCHED / APPARENT
ESTIMATED WET SEASON WATER TABLE ELEVATION:
INCHES
[ABOVE / BELOW]
EXISTING GRADE
ABOVE / BELOW
HIGH WATER TABLE VEGETATION: [ ] YES
[ ] NO
MOTTLING: [ ] YES
[ ] NO
DEPTH:
INCHES
SOIL TEXTURE/LOADING RATE FOR SYSTEM SIZING:
DEPTH OF EXCAVATION:
INCHES
DRAINFIELD CONFIGURATION: [ ] TRENCH
[ ] BED
[ ] OTHER (SPECIFY)
REMARKS/ADDITIONAL CRITERIA:
SITE EVALUATED BY:
DATE:
Page 3 of 4
DH 4015, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.001, FAC
INSTRUCTIONS:
PERMIT #:
Permit tracking number assigned 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#:
27 character number for property (property appraiser ID # or section/township/range/parcel number).
PROPERTY SIZE:
Check if property size 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 (residential) or Table 2 (non-residential), Chapter 64E-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 gallons per day 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 64E-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 met to all listed features. Actual measurements must be recorded or "NA" for non
applicable 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 mottling is present and depth.
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 documentation 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
