Form DH4016 Page 1 "Onsite Sewage Treatment and Disposal System Construction Permit" - Florida

What Is Form DH4016 Page 1?

This is a legal form that was released by the Florida Department of Environmental Protection - 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 Environmental Protection;
  • 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 DH4016 Page 1 by clicking the link below or browse more documents and templates provided by the Florida Department of Environmental Protection.

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Download Form DH4016 Page 1 "Onsite Sewage Treatment and Disposal System Construction Permit" - Florida

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PERMIT NO. ____________
STATE OF FLORIDA
DATE PAID: ____________
DEPARTMENT OF HEALTH
FEE PAID:
____________
ONSITE SEWAGE TREATM
ENT AND DISPOSAL SYSTEM
RECEIPT #: ____________
CONSTRUCTION PERMIT
_______________________
CONSTRUCTION PERMIT FOR:
[
]
New System
[
]
Existing System
[
]
Holding Tank
[
]
Innovative
[
]
Repair
[
]
Abandonment
[
]
Temporary
[
]
APPLICANT:
PROPERTY ADDRESS:
LOT:
BLOCK:
SUBDIVISION:
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
PROPERTY ID #: _
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E-6, F.A.C.
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME.
ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION.
SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [
] GALLONS / GPD SEPTIC TANK/AEROBIC UNIT CAPACITY
MULTI-CHAMBERED/IN-SERIES [
]
A [
] GALLONS / GPD
CAPACITY
MULTI-CHAMBERED/IN-SERIES [
]
N [
] GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [
] GALLONS DOSING TANK CAPACITY
[
] GALLONS @ [
] DOSES PER 24 HRS
# PUMPS [
]
D [
] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [
] SQUARE FEET
SYSTEM
A TYPE SYSTEM:
[
] STANDARD
[
] FILLED
[
] MOUND
[
] _
I CONFIGURATION:
[
] TRENCH
[
] BED
[
]
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE
[
] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [
] INCHES
EXCAVATION REQUIRED: [
] INCHES
O
T
H
E
R
SPECIFICATIONS BY:
TITLE:
APPROVED BY:
TITLE:
CHD
DATE ISSUED:
EXPIRATION DATE:
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated:
64E-6.003, FAC
Page 1 of 3
PERMIT NO. ____________
STATE OF FLORIDA
DATE PAID: ____________
DEPARTMENT OF HEALTH
FEE PAID:
____________
ONSITE SEWAGE TREATM
ENT AND DISPOSAL SYSTEM
RECEIPT #: ____________
CONSTRUCTION PERMIT
_______________________
CONSTRUCTION PERMIT FOR:
[
]
New System
[
]
Existing System
[
]
Holding Tank
[
]
Innovative
[
]
Repair
[
]
Abandonment
[
]
Temporary
[
]
APPLICANT:
PROPERTY ADDRESS:
LOT:
BLOCK:
SUBDIVISION:
[SECTION, TOWNSHIP, RANGE, PARCEL NUMBER]
PROPERTY ID #: _
[OR TAX ID NUMBER]
SYSTEM MUST BE CONSTRUCTED IN ACCORDANCE WITH SPECIFICATIONS AND STANDARDS OF SECTION 381.0065,
F.S., AND CHAPTER 64E-6, F.A.C.
DEPARTMENT APPROVAL OF SYSTEM DOES NOT GUARANTEE SATISFACTORY
PERFORMANCE FOR ANY SPECIFIC PERIOD OF TIME.
ANY CHANGE IN MATERIAL FACTS, WHICH SERVED AS A
BASIS FOR ISSUANCE OF THIS PERMIT, REQUIRE THE APPLICANT TO MODIFY THE PERMIT APPLICATION.
SUCH MODIFICATIONS MAY RESULT IN THIS PERMIT BEING MADE NULL AND VOID.
ISSUANCE OF THIS PERMIT
DOES NOT EXEMPT THE APPLICANT FROM COMPLIANCE WITH OTHER FEDERAL, STATE, OR LOCAL PERMITTING
REQUIRED FOR DEVELOPMENT OF THIS PROPERTY.
SYSTEM DESIGN AND SPECIFICATIONS
T [
] GALLONS / GPD SEPTIC TANK/AEROBIC UNIT CAPACITY
MULTI-CHAMBERED/IN-SERIES [
]
A [
] GALLONS / GPD
CAPACITY
MULTI-CHAMBERED/IN-SERIES [
]
N [
] GALLONS GREASE INTERCEPTOR CAPACITY
[MAXIMUM CAPACITY SINGLE TANK: 1250 GALLONS]
K [
] GALLONS DOSING TANK CAPACITY
[
] GALLONS @ [
] DOSES PER 24 HRS
# PUMPS [
]
D [
] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
R [
] SQUARE FEET
SYSTEM
A TYPE SYSTEM:
[
] STANDARD
[
] FILLED
[
] MOUND
[
] _
I CONFIGURATION:
[
] TRENCH
[
] BED
[
]
N
F LOCATION OF BENCHMARK:
I ELEVATION OF PROPOSED SYSTEM SITE [
] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
E BOTTOM OF DRAINFIELD TO BE
[
] [INCHES/FT] [ABOVE/BELOW] BENCHMARK/REFERENCE POINT
L
D FILL REQUIRED: [
] INCHES
EXCAVATION REQUIRED: [
] INCHES
O
T
H
E
R
SPECIFICATIONS BY:
TITLE:
APPROVED BY:
TITLE:
CHD
DATE ISSUED:
EXPIRATION DATE:
DH 4016, 08/09 (Obsoletes all previous editions which may not be used)
Incorporated:
64E-6.003, FAC
Page 1 of 3
INSTRUCTIONS:
PERMIT NUMBER:
Permit tracking number assigned by CPHU.
CONSTRUCTION
PERMIT FOR:
Check type of permit, if "Other" specify type in blank.
APPLICANT:
Property owner's full name.
TELEPHONE:
Telephone number for applicant or agent
AGENT:
Property owner's legally authorized representative.
MAILING ADDRESS:
P.O. Box or street mailing address for applicant or agent.
LOT, BLOCK, SUBDIVISION or
PROPERTY ID#:
27 character id number for property. (CHD may require property appraiser ID # or section/township/range/parcel number)
SYSTEM DESIGN AND
SPECIFICATIONS:
TANK:
Minimum specifications from Chapter 64E-6, FAC.
DRAINFIELD:
Minimum specifications from Chapter 64E-6, FAC.
OTHER:
Other specifications, such as operating permit requirements, low-volume flush toilets, variance provisos.
SPECIFICATIONS BY:
Name of individual providing specifications. If designed by a registered engineer must be sealed.
APPROVED BY:
County Health Department (CHD) personnel reviewing and approving permit.
DATE ISSUED:
Date permit is issued by CHD
EXPIRATION DATE:
Eighteen months from date issued if the system has not been installed. Permits for system repairs become void 90 days from the
date issued.
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