Application (PDF 162kb) - Orange County Health Department

Rick ScottGovernornFLORIDA DEPARTMENT OFHEALT IJohn H. Armstrong, MDState Surgeon GeneralProcedure for Applying for Abandonment of a Septic Tank"Whenever the use of an onsite sewage treatment and disposal system is discontinuedfollowing connection to a sanitary sewer, following condemnation or demolition orremoval or destruction, of a building or property, or discontinuing the use of a septictank and replacement with another septic tank, the system shall be abandoned within90days and any further use of the system for any purpose shall be prohibited. "(64E-6.011FAC)To apply for the Abandonment of a Septic Tank the following procedure is required:(1) An Application must be filled out (form DH 4015)(2) A Site Plan must be provided, it must show:a. The Boundaries of the lot(s)b. The Location of the Structure(s) on the lot(s)c. The Location of the Septic Tank(s) on the lot(s)(3) The Reason for Abandoning the Septic Tank must be noted(4) If the applicant is not the property owner, where the agent is not a licensedcontractor pursuant to the requirements of Chapter 489, Florida Statutes, aLetter of Authorization from the property owner assigning authority for therepresentative to act on the owner's behalf is required (Chapter 64E-6.0044(2),F.A.C.).(5) A fee of $107.00 must be paid at the time of the application.All forms can be found at http://www.orchd.com/evh/(Link: Onsite Sewage DisposalRev 7/17/22OrangeCountyHealth800 N Mercy Drive, Suite #1 Department (407)521-2630. Fax (407) 445-7493FLORIDA DEPARTMENTOrlando, FL 32808 ww.orchd.com/evh • www.orchd.mobiOF HEALTHProtecting Your Health...It's What We Do

Rick ScottGovernorFLORIDA DEPARTMENT OF nHEALTJohn H. Armstrong, MDState Surgeon GeneralProcedimiento para Aplicar para el Abandono de un Pozo Septico'Whenever the use of an onsite sewage treatment and disposal system is discontinued following connection to asanitary sewer, following condemnation or demolition or removal or destruction, of a building or property, ordiscontinuing the use of a septic tank and replacement with another septic tank, the system shall be abandonedwithin 90 days and any further use of the system for any purpose shall be prohibited." (64E-6.011, FAG)"Cada vez que el uso de un septic° residencial tratamiento de aguas de residuales en local esdescontinuado proseguido por la conexion a servicio de desagOe public°, proseguido por lacondenaciOn o demolicion o remuevo o destruccion, de un edificio 6 propiedad, 6 eldescontinuo de uso de un tanque septic° y reemplazo con otro tanque septic°, el sistema debeser abandonado dentro de los 90 dias y cualquier uso de el sistema para cualquier uso debede ser prohibido." (TraducciOn literal de 64 E-6.011FAC)Para aplicar por el Abandono de un Tanque Septic° el siguiente procedimiento es requerido:(1) Completar una aplicacion (Aplicacion DH 4015)(2) Un plan de suelo debe ser proporcionado, y debe mostrar lo siguiente:a. Umite de lote(s)b. Localizacion de la estructura(s) en el lote(s)c. LocalizaciOn de el tanque septic° en el lote(s)(3) La raz6n para abandonar el pozo septic° debe ser anotada(4) Una carta de autorizaciOn de el dueno 6 propietario asignando autoridad para elrepresentante para actuar en su nombre (64E-6.004(2), FAC)(5) Un pago 6 cuota de $107.00 deben ser pagados al entregar la aplicaciOn.Todas las aplicaciones las puede encontrar en http://www.orchd.com/evh (Link: OnsiteSewage Disposal)Revised 07/17/12OrangeCountyHealth800 N Mercy Drive, Suite #1 Department (407)521-2630 • Fax (407) 445-7493FLORIDA DEPARTMENTOrlando, FL 32808 ww.orchd.com/evh • www.orchd.mobiOF HEALTHProtecting Your Health...It's What We Do

APPLICANT:AGENT:TELEPHONE:MAILING ADDRESS:LOT, BLOCK,SUBDIVISION:DATE OF SUBDIVISION:PROPERTY ID#:ZONING:PROPERTY SIZE:WATER SUPPLY:SEWER AVAILABILITY:PROPERTY ADDRESS:DIRECTIONS:BUILDING INFORMATION:TYPE ESTABLISHMENT:NO. BEDROOMS:BUILDING AREA:BUSINESS ACTIVITY:FIXTURES:SIGNATURE / DATE:Property owner's full name.Property owner's legally authorized representative.Telephone number for applicant or agent.P.O. box or street, city, state and zip code mailing address for applicant or agent.Lot, block, and subdivision for lot (recorded or unrecorded subdivision). If lot is not in arecorded subdivision, a copy of the lot legal description or deed must be attached.Official date of subdivision recorded in county plat books (month/day/year) or date lotoriginally recorded. Dividing an approved lot into two or more parcels for the purpose ofconveying ownership shall be considered a subdivision of the lot.27 character number for property. CHD may require property appraiser ID # orsection/township/range/parcel number.Specify zoning and whether or not property is in UM zoning or equivalent usage.Net usable area of property in acres (square footage divided by 43,560 square feet)exclusive of all paved areas and prepared road beds within public rights-of way oreasements and exclusive of streams, lakes, normally wet drainage ditches, marshes, orother such bodies of water. Contiguous unpaved and non-compacted road rights-of-wayand easements with no subsurface obstructions may be included in calculating lot area.Check private or public 2000 gallons per day.Is sewer available as per 381.0065, Florida Statutes, and distance to sewer in feet.Street address for property. For lots without an assigned street address, indicate streetor road and locale in county.Provide detailed instructions to lot or attach an area map showing lot location.Check residential or commercial.List type of establishment from Table II, Chapter 64E-6, FAC. Examples: single family,single wide mobile home, restaurant, doctor's office.Count all rooms designed primarily for sleeping and those areas expected to routinelyprovide sleeping accommodations for occupants.Total square footage of enclosed habitable area of dwelling unit, excluding garage,carport, exterior storage shed, or open or fully screened patios or decks. Based onoutside measurements for each story of structure.For commercial/institutional applications only. List number of employees, shifts, andhours of operation, or other information required by Table II, Chapter 64E-6, FAC.Mark Floor/Equipment Drains or Others and specify item or "NA" if not applicable.Signature of applicant or agent. Date application submitted to the CHD with appropriatefees and attachments.ATTACHMENTS: A site plan drawn to scale, showing boundaries with dimensions, locations of residences orbuildings, swimming pools, recorded easements, onsite sewage disposal system components and location, slope ofproperty, any existing or proposed wells, drainage features, filled areas, obstructed areas, and surface water. Location ofwells, onsite sewage disposal systems, surface waters, and other pertinent facilities or features on adjacent property, ifthe features are with 75 feet of the applicant lot. Location of any public well within 200 feet of lot. For residences, a floorplan (residences) showing number of bedrooms and building area of each unit. For nonresidential establishments, a floorplan showing the square footage of the establishment, all plumbing drains and fixture types, and other features necessaryto determine composition and quantity of wastewater.

Rick ScottGovernorFLORIDA DEPARTMENT OF 7---)HEALTJohn H. Armstrong, MDState Surgeon GeneralCREDIT CARD/CHECK CARD VERIFICATION AUTHORIZATION FORMRequesting Company:Credit Card Number:Printed Name:Card Holder's Signature:Request Date:Expiration Date:Phone Number:(Required)Total Charged:Permit Number(s):(If known) orPermit Address(s):Service Type Requested (i.e.; repair permit, re-inspection fee, swimming pool permit, wellpermit, etc.):Applicant(s) Name on Permit:CARDHOLDER BILLING ADDRESS:Comments:The credit card will be charged upon receipt unless otherwise noted in the comments section.The Orange County Health Department hereby acknowledges that the signature above denotesauthorization to charge the referenced account for payment for this (these) specific services(s).Charges to the above account will not exceed the agreed upon total. The Orange CountyHealth Department also acknowledges that additional charges will not be made unlessadditional written authorization is received and specified on this or a subsequent Credit CardVerification/Authorization Form.If you have any questions regarding these charges, please feel free to contact our officeRevised 07/17/12OrangeCountyHealth800 N Mercy Drive, Suite #1Orlando, FL 32808Department (407)521-2630. Fax (407) 445-7493FLORIDA DEPARTMENTww.orchd.com/evh • www.orchd.mobiOF HEALTHProtecting Your Health...It's What We Do