Instructions/Explanations for InteragencyCoordination ofRegulated Establishments /Evaluation of Onsite

Sewage and Water SupplyCapacity

As indicatedon the evaluation page, theevaluation isto ensure facilities/businesses regulatedby the Department of Business andProfessional Regulation (DBPR), Department of Agriculture and Consumer Services (DACS),Department of Children and Families (DCF), Agency for Health Care Administration (AHCA) and Agency for Persons with Disabilities (APD) are evaluated for adequatewaterand sewageservicesbefore opening orexpanding operations.When the evaluation form is completed, it is returned to the licensing agencyto indicate whether or notthe water andsewageservices are adequate andhave been approvedby the appropriateagency or utility authority.The evaluation form is used to facilitate and expedite the approval process.Theevaluation form is not intended to be used for existingor failing systems notassociatedwith anychanges to the operation.Ifthe business/facilityis served by onsite wateror onsite

septic system(one or both), the evaluation formmustbe completedby the Department of Health/County HealthDepartment (DOH/CHD) insections 2 and/or 3 and the regulatingagency must not complete licensing until the DOH/CHDhas approvedthe onsite septic and/or water system.

Section 1 –Evaluation Request For/Licensing Agency

Thissection should be completed by the applicant.Ensurecorrect information regarding the applicant and facility is provided.Indicate by checking the appropriate box ifthisrequest is for a new facility, expansion/remodeling, or change inoccupancy/tenancy.

New – A newly constructed business/facility

Expansion/remodeling – a business/facility that is being remodeled or upgraded.This could be due to an increase in seating (food service establishment), changein food operation (e.g.,single service to full service, an increase in operation hours, additionof a deli or foodpreparation in a convenience store, etc.), in increase of the food preparation in afood outlet or bakery, increase in the residents in aadult living facility andincrease in students in a childcare facility and more.

Change in Occupancy/Tenancy – an existing business that haschanged occupancy or tenancy resulting in changes to the business operation.

Indicate the appropriate licensing agency, permit number (ifavailable), contact person with the licensing agency, phonenumber and any comments.In addition, complete the establishment information.Clearly indicate the name and physical address of the business/establishment, the type of business (i.e., restaurant, conveniencestore, bakery, childcare, adult living facility etc.)Provide the name of a contact person and phone number.

Section 2 –Water

Thissection is to be completed by the DOH/CHD, Department of EnvironmentalProtection (DEP) or the Utility Authority.

If served by Municipal/Public Water:

Indicate the name of the supplier.Youmay provide theappropriate documentation requestedby the licensing agency to validate this or have the Municipal/PublicWater provider complete the evaluationsection.

If served by an OnsiteWaterSystem regulated by DOH:

The entire portion of Section #2 should be completedby DOH/CHD.Inthis section list the permit number ifa permit has been issued.Indicate the type of watersystem.List the result of the evaluationas either approved or denied.In commentssection list anyconditions of approval or disapproval thatmay be necessary.At the bottom of the form indicate the name andtitle ofthe Health Official reviewing or approving the evaluation including asignature, date, office address and phone number.The licensing agency needs this information for reference, questions andany validationthat may be necessary.

Section 3 -Wastewater

Thissection is to be completed by the DOH/CHD, Department of EnvironmentalProtection (DEP)or the Utility Authority.

If served by aMunicipal/Public Sewer:

Indicate the name of the supplier.Youmay provide theappropriate documentation requestedby the licensing agency to validate this or have the Municipal/PublicSewer provider complete the evaluationsection.

If served by aSeptic/Onsite Wastewater System:

This entire portion of Section #3 should be completedby theDOH/CHD.In this section list the permit number if a permit has been issued.List the result of the evaluation as either approved or denied.If approved, list the conditions of approval. The conditions include; foodservice establishments that are designed for singleservice utensils only, the number of seats approved,the hours of operation, in group care/institutional facilities the number of residents or students, in adult living facilities the number of bedor clients, otherconditions andwhether or not foodservice is provided.In the commentssection, other details orconditions of permitting/approval can be listed.Atthe bottom of the form indicate the name and title of the Health Official reviewing or approving the evaluation including a signature, date, office address and phone number.The licensing agency needs this information for reference, questions and anyvalidation thatmay be necessary.

INTERAGENCY COORDINATION OFREGULATEDESTABLISHMENTS- DOH/DACS/DBPR/DCF/AHCA/APD EVALUATIONOFONSITESEWAGE(SEPTIC) AND WATER SUPPLY CAPACITY

This evaluation is to ensure certain regulated facilities/businesses are evaluated for adequatewater and sewage services before opening or expanding operations.Ifthe facility/business ison a DOH regulated onsitewell or onsiteseptic system,completion ofthis evaluation will facilitateand expedite the approvalprocess.Please return to the appropriate licensing agency whencomplete.

Completedby Applicant / Section 1 - EVALUATIONREQUEST FOR/LICENSING AGENCY
☐ New
(new buildingor structure) / ☐ Expansion / Remodeling / ☐ Change in Occupancy/Tenancy
(increase in seating/residents/other)
Licensing Agency:
☐DBPR☐DACS☐DCF☐AHCA☐APD / License Number:
Contact Person: / Phone: / FAX:
Comments:
ESTABLISHMENT INFORMATION
EstablishmentName: / Typeof Establishment:
Address: / Contact Person / Phone#:
City: / County: / Zip:

s

Section 3 –WASTEWATER
The above named facility/business uses the followingwastewaterdisposal system (choose one type), and complete evaluation:
Completed byDOH/CHD, DEPor UtilityAuthority
☐Municipal/Public Sewer / Name of Supplier:
☐Septic System (OnsiteWastewater) / PermitNumber:
SYSTEMEVALUATION RESULT:(thissectionbelownormallyonlycompletedbyDOHifonasepticsystem)
☐Approved / ☐Single-Service Utensils Only / ☐Number ofResidents/Students
☐Number ofSeats Permitted / ☐Number ofBeds/Clients
☐Denied / ☐Hours of Operation / ☐OtherConditions (see comments)
(see comments) / ☐Food ServiceYes / ☐ / No☐
Comments:
Name & Title
(Printed) / CountyHealthDepartment/DOH/Utility
Signature / Date
Address / Phone