Form DH4012A "Agricultural Use Plan" - Florida

What Is Form DH4012A?

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 August 1, 2009;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DH4012A by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4012A "Agricultural Use Plan" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
AGRICULTURAL USE PLAN
Instructions:
1.
This form shall be submitted by persons maintaining property upon which treated septage and other domestic wastewater residuals regulated by the
department are to be applied. The application of these wastes may only be approved by the department when used as a part of an ongoing
agricultural program, and application of treated septage and sludges shall be performed in such a manner so as not to exceed the needs of the crops
with respect to nitrogen or phosphorous. Chapter 64E-6.010, F.A.C. specifies the manner in which land application of septage and other domestic
sludges may be land applied. Copies of this rule may be obtained from any DOH county health department or upon request from: DOH
Environmental Health Services, 4052 Bald Cypress Way, Bin# A08, Tallahassee, Florida 32399-1713.
2.
A copy of this agricultural use plan must be filled out completely and submitted to the DOH county health department in the county in which your
property is located. A separate form must be completed for each parcel upon which septage and other domestic sludges will be land applied. This
form shall be completed and submitted annually to the DOH county health department and shall be available to all companies authorized to dispose of
treated septage and other domestic sludges on your property.
3.
By allowing companies to dispose of treated septage and other domestic sludges on you property, you also agree to allow department employees to
enter onto your property upon proper notice and during reasonable hours to evaluate the compliance of your site with provisions set forth in Chapter
64E-6, F.A.C.
4.
Additional information necessary to evaluate the suitability of your property for land application of septage shall be submitted upon the request of the
DOH county health department prior to allowing the treated septage and other domestic sludges to be land applied.
PART I
DISPOSAL SITE INFORMATION
1. Location:
Property Owner:
Owner's Address:
City:
State:
Zip:
Property Address:
Section:
Township:
Range:
Parcel:
County:
Directions to Property:
Will someone other than the Owner be managing the site: Yes
No
If yes, provide the following:
Manager's Name:
Address:
City
State:
Zip:
Phone:
2. Attach a map of appropriate scale to show site location and boundary of the land application area. The following information
shall be indicated on the site map:
a. Water supply wells on the site or adjacent to the site;
b. Surface waters on the site and adjacent to the site; and,
c. Occupied buildings on the site or adjacent to the site
The boundary of the land application area shall be shown to conform to the following requirements:
a. 3000 Feet from a Class I water body or Outstanding Florida Water as defined in Chapter 17-302, F.A.C.;
b. 200 Feet to any other surface water except canals or bodies of water used for irrigation, that are located completely
within the site and will not discharge from the site;
c. 300 Feet from any shallow private water supply well and 500 feet from any shallow public water supply well;
d. 200 feet from any visible evidence of sinkholes or other natural or manmade conduits that could allow direct
contamination of groundwater.
3. Total Acreage of Site:
Acreage to be applied:
Soil pH:
4. Soil survey information should be attached that demonstrates that the seasonal high ground water is not within 24 inches of
the ground surface. If the seasonal high ground water level will be within 24 inches of the ground surface or is undetermined,
the ground water level shall be monitored prior to each application of septage. The location of these monitoring points shall
be shown on the site map. If the seasonal high ground water level is determined to be within 24 inches of the ground surface
or is undetermined, state what provisions will be made to assure that septage and other domestic residuals will be handled in
a sanitary manner, will not be disposed of improperly, and will not create a nuisance condition. (examples of adequate
assurances are onsite storage facilities, off site storage facilities, alternative disposal sites, etc.)
DH Form 4012A, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.010, FAC
Page 1 of 2
STATE OF FLORIDA
DEPARTMENT OF HEALTH
AGRICULTURAL USE PLAN
Instructions:
1.
This form shall be submitted by persons maintaining property upon which treated septage and other domestic wastewater residuals regulated by the
department are to be applied. The application of these wastes may only be approved by the department when used as a part of an ongoing
agricultural program, and application of treated septage and sludges shall be performed in such a manner so as not to exceed the needs of the crops
with respect to nitrogen or phosphorous. Chapter 64E-6.010, F.A.C. specifies the manner in which land application of septage and other domestic
sludges may be land applied. Copies of this rule may be obtained from any DOH county health department or upon request from: DOH
Environmental Health Services, 4052 Bald Cypress Way, Bin# A08, Tallahassee, Florida 32399-1713.
2.
A copy of this agricultural use plan must be filled out completely and submitted to the DOH county health department in the county in which your
property is located. A separate form must be completed for each parcel upon which septage and other domestic sludges will be land applied. This
form shall be completed and submitted annually to the DOH county health department and shall be available to all companies authorized to dispose of
treated septage and other domestic sludges on your property.
3.
By allowing companies to dispose of treated septage and other domestic sludges on you property, you also agree to allow department employees to
enter onto your property upon proper notice and during reasonable hours to evaluate the compliance of your site with provisions set forth in Chapter
64E-6, F.A.C.
4.
Additional information necessary to evaluate the suitability of your property for land application of septage shall be submitted upon the request of the
DOH county health department prior to allowing the treated septage and other domestic sludges to be land applied.
PART I
DISPOSAL SITE INFORMATION
1. Location:
Property Owner:
Owner's Address:
City:
State:
Zip:
Property Address:
Section:
Township:
Range:
Parcel:
County:
Directions to Property:
Will someone other than the Owner be managing the site: Yes
No
If yes, provide the following:
Manager's Name:
Address:
City
State:
Zip:
Phone:
2. Attach a map of appropriate scale to show site location and boundary of the land application area. The following information
shall be indicated on the site map:
a. Water supply wells on the site or adjacent to the site;
b. Surface waters on the site and adjacent to the site; and,
c. Occupied buildings on the site or adjacent to the site
The boundary of the land application area shall be shown to conform to the following requirements:
a. 3000 Feet from a Class I water body or Outstanding Florida Water as defined in Chapter 17-302, F.A.C.;
b. 200 Feet to any other surface water except canals or bodies of water used for irrigation, that are located completely
within the site and will not discharge from the site;
c. 300 Feet from any shallow private water supply well and 500 feet from any shallow public water supply well;
d. 200 feet from any visible evidence of sinkholes or other natural or manmade conduits that could allow direct
contamination of groundwater.
3. Total Acreage of Site:
Acreage to be applied:
Soil pH:
4. Soil survey information should be attached that demonstrates that the seasonal high ground water is not within 24 inches of
the ground surface. If the seasonal high ground water level will be within 24 inches of the ground surface or is undetermined,
the ground water level shall be monitored prior to each application of septage. The location of these monitoring points shall
be shown on the site map. If the seasonal high ground water level is determined to be within 24 inches of the ground surface
or is undetermined, state what provisions will be made to assure that septage and other domestic residuals will be handled in
a sanitary manner, will not be disposed of improperly, and will not create a nuisance condition. (examples of adequate
assurances are onsite storage facilities, off site storage facilities, alternative disposal sites, etc.)
DH Form 4012A, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.010, FAC
Page 1 of 2
PART I
CONTINUED
5. Attach a USGS or other suitable topographic map to demonstrate that site slopes do not exceed 8 percent. If slopes exceed
2 percent, attach a conservation plan prepared by or approved by the Soil Conservation Service or a stormwater
management plan prepared in accordance with the provisions of Chapter 17-25, F.A.C., by an engineer registered in Florida.
The plan shall demonstrate that suitable soil infiltration rates and stormwater control measures exist at the site to retain runoff
generated by storms up to a 10-year, 1-hour event.
Do slopes exceed 8 percent: Yes
No
Do slopes exceed 2 percent: Yes
No
Will septage and other domestic sludges be stored at the application site Yes
No
If yes, indicate the location of storage facilities and describe the provisions for storage:
6. Crop(s) or vegetation type (name):
6A. Complete section 6A if you are in an area where septage application is limited by nitrogen.
1. Nitrogen demand is:
lbs./acre/year as determined by :
Recommendations of Soil Conservation Service or Institute of Food and Agricultural Science (attach documentation)
Other; (identify and attach supporting documentation)
The maximum allowable nitrogen application rate is 500 pounds (40,000 gallons of septage) per acre per year.
6B. Complete section 6B if you are in an area where septage application is limited by phosphorous.
1. Available Phosphorous Soil Test Result (Mehlich-1 soil test)
ppm
2. Phosphorous demand is:
lbs./acre/year
P
P
O
as determined by :
2
5
UF/IFAS Standardized Fertilization Recommendations for Agronomic Crops.
NRCS Recommendations
Other; (identify and attach supporting documentation)
The maximum allowable phosphorous application rate is 40 pounds (12,000 gallons of septage) per acre per year.
6C. The Septage Application Rate for the entire site is
gallons/year
PART II WASTE GENERATORS:
List all companies authorized to land apply treated septage to your property and the gallonage amounts expected to be applied
to your property by each company (attach additional sheets if necessary).
1. Company:
Number of trucks allowed on property:
Company Address:
City:
State:
Zip:
Contact Person with the Company
Phone:
Maximum amount of septage to be accepted from this company on an annual basis:
gallons
2. Company:
Number of trucks allowed on property:
Company Address:
City:
State:
Zip:
Contact Person with the Company
Phone:
Maximum amount of septage to be accepted from this company on an annual basis:
gallons
3. Company:
Number of trucks allowed on property:
Company Address:
City:
State:
Zip:
Contact Person with the Company
Phone:
Maximum amount of septage to be accepted from this company on an annual basis:
gallons
I agree to operate this site in conformance with all applicable rules and standards and agree to cease land application of septage and other domestic sludges if
the department determines that continued operation constitutes a nuisance injurious to the public's health. I accept the obligation to maintain records as may be
required and will file an amended or updated plan at least annually.
Owner's Signature:
Date
/
/
Received by:
CHD:
Date
/
/
Disapproved:
Date
/
/
Reviewed by:
Approved:
Date
/
/
DH 4012A, 08/09 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.010, FAC
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