Form DH4057 "Application for Variance From Chapter 64e-6, Fac" - Florida

What Is Form DH4057?

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;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DH4057 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4057 "Application for Variance From Chapter 64e-6, Fac" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
Variance Application Number
APPLICATION FOR VARIANCE FROM CHAPTER 64E-6, FAC
STANDARDS FOR ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS
______________________
Authority: Chapter 381, Florida Statutes
Onsite Sewage Office Use Only
Chapter 64E-6, Florida Administrative Code
Follow the instructions on the back of this form for assembling your application for variance. Eight (8) copies of this form and supporting documentation
must be submitted with the required fee to your local county health department. Your application must be reviewed by the local county health
department and the completed application received by the Bureau of Onsite Sewage Programs in Tallahassee no later than the 15th of the month to be
placed on the agenda for the next monthly meeting of the variance review and advisory committee. If the 15th falls on a weekend or legal holiday, the
deadline for receipt will be the next regular working day. If the variance request involves setbacks from wells or surface waters, the separation of the
drainfield from the estimated wet season high water table, or the authorized sewage flow of the property, the county health department must post a sign
on the property giving notice of the application for variance.
PART I - GENERAL INFORMATION
(To be completed by the applicant. See instructions on the back of this form.)
(TYPE OR PRINT LEGIBLY)
APPLICANT INFORMATION
Property Owner:
Phone:(W) (
)
(H) (
)
Owner's Agent:
Phone:(W) (
)
(H) (
)
Mailing Address:
City:
State:
Zip:
PROPERTY INFORMATION
Property Street Address:
City:
County:
Lot:
Block:
Subdivision:
Unit:
Section:
Township:
Range:
Parcel Number:
Metes & Bounds Description (Attach property legal description)
VARIANCE REQUEST INFORMATION
A variance may not be granted under section 381.0065, FS, until the department is satisfied the following conditions have been met.
Address each item explaining how your variance request satisfies the statutory conditions for a variance. Attach a separate sheet if necessary.
1. Please explain how your variance request satisfies the statutory requirement that the hardship was not caused intentionally by the action of the
applicant.
2. Please explain how your variance request satisfies the statutory requirement that no reasonable alternative, taking into consideration factors such as
cost, exists for the treatment of the sewage.
3. Please explain how your variance request satisfies the statutory requirement that the discharge from the onsite sewage treatment and disposal
system will not adversely affect the health of the applicant or the public or significantly degrade the groundwater or surface waters.
I attest the above information is true. I acknowledge that in the submission of this variance request, I hereby authorize department employees to enter
onto my property to conduct inspection activities and to post public notice of this variance request.
Signature of Owner or Agent:
Date:______/______/______
DH 4057, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.004, FAC
Page 1 of 2
STATE OF FLORIDA
DEPARTMENT OF HEALTH
Variance Application Number
APPLICATION FOR VARIANCE FROM CHAPTER 64E-6, FAC
STANDARDS FOR ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEMS
______________________
Authority: Chapter 381, Florida Statutes
Onsite Sewage Office Use Only
Chapter 64E-6, Florida Administrative Code
Follow the instructions on the back of this form for assembling your application for variance. Eight (8) copies of this form and supporting documentation
must be submitted with the required fee to your local county health department. Your application must be reviewed by the local county health
department and the completed application received by the Bureau of Onsite Sewage Programs in Tallahassee no later than the 15th of the month to be
placed on the agenda for the next monthly meeting of the variance review and advisory committee. If the 15th falls on a weekend or legal holiday, the
deadline for receipt will be the next regular working day. If the variance request involves setbacks from wells or surface waters, the separation of the
drainfield from the estimated wet season high water table, or the authorized sewage flow of the property, the county health department must post a sign
on the property giving notice of the application for variance.
PART I - GENERAL INFORMATION
(To be completed by the applicant. See instructions on the back of this form.)
(TYPE OR PRINT LEGIBLY)
APPLICANT INFORMATION
Property Owner:
Phone:(W) (
)
(H) (
)
Owner's Agent:
Phone:(W) (
)
(H) (
)
Mailing Address:
City:
State:
Zip:
PROPERTY INFORMATION
Property Street Address:
City:
County:
Lot:
Block:
Subdivision:
Unit:
Section:
Township:
Range:
Parcel Number:
Metes & Bounds Description (Attach property legal description)
VARIANCE REQUEST INFORMATION
A variance may not be granted under section 381.0065, FS, until the department is satisfied the following conditions have been met.
Address each item explaining how your variance request satisfies the statutory conditions for a variance. Attach a separate sheet if necessary.
1. Please explain how your variance request satisfies the statutory requirement that the hardship was not caused intentionally by the action of the
applicant.
2. Please explain how your variance request satisfies the statutory requirement that no reasonable alternative, taking into consideration factors such as
cost, exists for the treatment of the sewage.
3. Please explain how your variance request satisfies the statutory requirement that the discharge from the onsite sewage treatment and disposal
system will not adversely affect the health of the applicant or the public or significantly degrade the groundwater or surface waters.
I attest the above information is true. I acknowledge that in the submission of this variance request, I hereby authorize department employees to enter
onto my property to conduct inspection activities and to post public notice of this variance request.
Signature of Owner or Agent:
Date:______/______/______
DH 4057, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.004, FAC
Page 1 of 2
INSTRUCTIONS FOR THE APPLICANT
Instructions for completing Part I, General Information
Property Owner:
Provide the name of the property owner as it appears on the property deed.
Property Owner Phone (H):
Provide the owner's home telephone number including the area code.
Property Owner Phone (W):
Provide the owner's work telephone number including the area code.
Owner's Agent:
Provide the name of the person (if any) legally authorized to represent the owner for the purpose of
requesting the variance.
Owner's Agent Phone (H):
Provide the owner's agent's home telephone number including the area code.
Owner's Agent Phone (W):
Provide the owner's agent's work telephone number including the area code.
Mailing Address:
Provide the owner's or the agent's complete mailing address. Letters returned for insufficient or
unknown address will be discarded.
Property Street Address:
Provide the number and street where the property is located.
Property Address City:
Provide the city or locale where the property is located.
Property Address County:
Provide the name of the county where the property is located.
Lot, Block, Subdivision, Unit:
If the subject property is in a subdivision, provide the legal description of the property in the spaces
provided. Do not write "See Attached".
Section, Township, Range, Parcel Number:
If the subject property is not in a subdivision, provide the section, township (including N or S), and
range (including E or W). Include the parcel number if appropriate. Do not write "See Attached."
Metes and Bounds Description:
"X" the box if the property is described by a metes and bounds description. Include the section,
township, range, and parcel number in the spaces above and attach the metes and bounds
description in the application package.
Variance Request Information:
State the facts that demonstrate the variance request meets the statutory conditions for granting a
variance. (Attach a separate sheet if necessary.)
Signature of Owner or Agent:
The owner or agent must sign this form attesting to the accuracy of the information provided and
authorizing department employees to enter onto the subject property. The name signed must be
either the name of the listed owner or the name of the listed agent.
Instructions for assembling the variance request information package
.
.
Supportive documentation should include eight (8) copies of the following:
.
. .
Completed application for onsite sewage treatment and disposal system construction permit
The denial letter from the County Health Department
. .
Completed site evaluation form
Completed plot plan, drawn to scale, showing pertinent features on your own and neighboring properties
Complete plans and specifications for the proposed system
. .
Any other information necessary for rendering a decision or which you feel is pertinent to your case
NOTE: If your variance request involves setback violations, your site plan should very clearly show the exact setback dimensions that will
be achieved if the variance is granted.
NOTE: If your variance request involves the setback to a public drinking water supply well, a written opinion from the agency regulating the
affected public drinking water system is required to be included in your application package.
NOTE: If your variance request involves jurisdiction of sewage treatment regulation, a letter from the agency having jurisdiction which
authorizes the Department of Health to take jurisdiction of the sewage flow is required.
The burden of presenting pertinent and supportive facts is the responsibility of the applicant. Failure to provide necessary information may result in the
application being denied or tabled.
Each of the eight copies of the variance application package should be assembled in the following order:
Variance Application Form, Part I
Variance Application Form, Part II
Continuation of Part I (if any)
Continuation of Part II (if any)
Denial letter
OSTDS Application for construction permit
Site evaluation
Site plan
Subdivision map
System design specifications
Other substantiating data
Each copy should be stapled together and all eight copies should be banded into a single bundle.
YOUR VARIANCE REQUEST IS INCOMPLETE WITHOUT PART II COMPLETED BY THE COUNTY HEALTH DEPARTMENT.
Your County Health Department will need ample time to review your completed variance request, perform their required field activities and prepare their
comments for your request. Check with your County Health Department concerning their deadline for submission of materials.
This completed application must be received by the Department of Health, Onsite Sewage Office in Tallahassee no later than the 15th of the month to
be placed on the agenda for the next monthly meeting of the variance review and advisory committee. If the 15th falls on a weekend or legal holiday,
the deadline for receipt will be the next regular working day.
PART II - COUNTY HEALTH DEPARTMENT INFORMATION
(To be completed by the county health department. See instructions on the back of this form.)
(TYPE OR PRINT LEGIBLY)
County Health Department Use Only
County Reference Number
Fee Paid $
Date
Receipt Number
REASON STANDARDS CANNOT BE MET
SPECIFIC SECTION(S) OF 381.0065, F.S.
REASON REQUIREMENTS IN THE SECTION CANNOT BE MET
OR 64E-6, F.A.C., INVOLVED IN REQUEST
(include the quantity of the deviation from the requirement)
SITE INFORMATION (Attach a completed site evaluation form)
C onnection distance from property to sanitary sewer is __________ feet/miles.
Lots in the vicinity of the subject property are generally:
Larger
Smaller
Same Size
Buildings on this property are:
Proposed
Existing
Under Construction
The OSTDS involved in this variance request is:
Proposed
Installed
Existing (Previously approved)
Proposed property use is:
Unchanged
Increased
New Use
Are there known OSTDS failures in the area?
No
Yes...Reason(s):
Lot is posted with a sign in accordance with the instructions on the back of this form.
Comments from the county health department (attach additional sheets if necessary):
Title:
Date:_____/_____/_____
Signature of Environmental Health Director or designee
NOTICE
1.
Procedures leading to the submission of this variance request must be in accordance with Chapter 120, Florida Statutes.
2.
This completed application must be received by the Department of Health, Onsite Sewage Office in Tallahassee no later than the 15th of the month
to be placed on the agenda for the next monthly meeting of the variance review and advisory committee. If the 15th falls on a weekend or legal
holiday, the deadline for receipt will be the next regular working day.
3.
If the variance request involves setbacks from wells or surface waters, the separation of the drainfield from the estimated wet season high water
table, or the authorized sewage flow of the property, the county health department shall post a sign on the property.
DH 4057, 08/09 (Obsoletes all previous editions which may not be used) Incorporated: 64E-6.004, FAC
Page 2 of 2
INSTRUCTIONS FOR THE COUNTY HEALTH DEPARTMENT
Instructions for completing Part II, Department-Provided Information
County Reference Number:
If your office has an application number or other case number used to track this file, list it here so it
can be included on variance correspondence.
Fee Paid:
Provide the amount of the variance application fee paid by the applicant.
Date:
Provide the date of the fee payment.
Receipt Number:
List the receipt number associated with the fee payment for purposes of audit control.
Specific Section(s) Involved in Request:
List the individual specific rule and statute citations which need to be varied in order to issue the
construction permit or approve the system or operation.
Reason Requirements Cannot be Met:
Provide a brief explanation of the reason the section of the rule or statute was listed, for example:
64E-6.005(3), F.A.C.
Proposed drainfield is 68 feet from surface water.
381.0065(4)(a), F.S.
Anticipated flow (300 gpd) exceeds authorized (285 gpd)
381.0065(4)(b), F.S.
Lot is in a subdivision that has 4.6 lots per acre.
Site Information:
Provide the distance from the property to the nearest sewer line and "X" the boxes that most closely
describe the property, the establishment and the system involved in the request.
Lot is Posted:
Mark an "X" in the box if the lot has been posted. The county health department shall post a sign on
the subject property under consideration for variance when reductions of setbacks from surface
waters, wells, wet season high water table, and minimum lot size criteria are requested. The sign
shall state that a variance from the standards of Chapter 64E-6, F.A.C. has been requested and
that information on the variance request may be obtained from the county health department.
The sign shall be posted in a conspicuous location on the lot no later than the 15th day of the
month preceding the variance meeting and shall remain posted for a minimum period of two
weeks.
Comments from the county health department:
Provide any facts that clarify the variance issues or that would be helpful to the committee in making
a recommendation or to the department in making a decision.
Signature of Environmental Director:
The signature of the Director of the Environmental Health or Engineering Section that administers the
Onsite Sewage Program, or his designee, is required.
Instructions for assembling the variance request information package
.
Supportive documentation should include eight (8) copies of the following:
.
.
Completed application for onsite sewage treatment and disposal system construction permit
.
The denial letter
. .
Completed site evaluation form
Completed plot plan, drawn to scale, showing pertinent features on the applicant’s property and neighboring properties
.
Complete plans and specifications for the proposed system
Any other information necessary for rendering a decision or which you feel is pertinent to the case
. .
NOTE: If the variance request involves setback violations, the site plan should very clearly show the exact setback dimensions that will be
achieved if the variance is granted.
NOTE: If the variance request involves the setback to a public drinking water supply well, a written opinion from the agency regulating the
affected public drinking water system is required to be included in the application package.
NOTE: If the variance request involves jurisdiction of sewage treatment regulation, a letter from the agency having jurisdiction which
authorizes the Department of Health to take jurisdiction of the sewage flow is required.
The burden of presenting pertinent and supportive facts is the responsibility of the applicant. Failure to provide necessary information may result in the
application being denied or tabled.
Each of the eight copies of the variance application package should be assembled in the following order:
Variance Application Form, Part I
Variance Application Form, Part II
Continuation of Part I (if any)
Continuation of Part II (if any)
Denial letter
OSTDS Application for construction permit
Site evaluation
Site plan
Subdivision map
System design specifications
Other substantiating data
Each copy should be stapled together and all eight copies should be banded into a single bundle.
The copies of the completed application package must be received by the Department of Health, Onsite Sewage Office in Tallahassee no later than the
15th of the month to be placed on the agenda for the next monthly meeting of the variance review and advisory committee. If the 15th falls on a
weekend or legal holiday, the deadline for receipt will be the next regular working day.
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