Instructions/Explanations for Interagency Coordination of Regulated Establishments /Evaluation of
Onsite Sewage and Water Supply Capacity
As indicated on the evaluation page, the evaluation is to ensure facilities/businesses regulated by the Department of Business and
Professional 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 adequate
water and sewage services before opening or expanding operations. When the evaluation form is completed, it is returned to the
licensing agency to indicate whether or not the water and sewage services are adequate and have been approved by the
appropriate agency or utility authority. The evaluation form is used to facilitate and expedite the approval process. The evaluation
form is not intended to be used for existing or failing systems not associated with any changes to the operation. If the
business/facility is served by onsite water or onsite septic system (one or both), the evaluation form must be completed by the
Department of Health/County Health Department (DOH/CHD) in sections 2 and/or 3 and the regulating agency must not complete
licensing until the DOH/CHD has approved the onsite septic and/or water system.
Section 1 – Evaluation Request For/Licensing Agency
This section should be completed by the applicant. Ensure correct information regarding the applicant and facility is provided.
Indicate by checking the appropriate box if this request is for a new facility, expansion/remodeling, or change in occupancy/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), change in food operation (e.g., single service to full service, an increase in
operation hours, addition of a deli or food preparation in a convenience store, etc.), an increase of the food
preparation in a food outlet or bakery, increase in the residents in a adult living facility and increase in students in a
childcare facility and more.
• Change in Occupancy/Tenancy – an existing business that has changed occupancy or tenancy resulting in changes to
the business operation.
Indicate the appropriate licensing agency, permit number (if available), contact person with the licensing agency, phone number 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, convenience store, bakery, childcare, adult living facility etc.) Provide
the name of a contact person and phone number.
Section 2 – Water
This section is to be completed by the DOH/CHD, Department of Environmental Protection (DEP) or the Utility Authority.
If served by a Municipal/Public Sewer:
Indicate the name of the supplier. You may provide the appropriate documentation requested by the licensing agency to validate
this or have the Municipal/Public Sewer provider complete the evaluation section.
If served by an Onsite Water System regulated by DOH:
The entire portion of Section #2 should be completed by DOH/CHD. In this section list the permit number if a permit has been
issued. Indicate the type of water system. List the result of the evaluation as either approved or denied. In comments section list
any conditions of approval or disapproval that may be necessary. At the 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 any validation that may be necessary.
Section 3 - Wastewater
This section is to be completed by the DOH/CHD, Department of Environmental Protection (DEP) or the Utility Authority.
If served by a Municipal/Public Sewer:
Indicate the name of the supplier. You may provide the appropriate documentation requested by the licensing agency to validate
this or have the Municipal/Public Sewer provider complete the evaluation section.
If served by a Septic/Onsite Wastewater System:
This entire portion of Section #3 should be completed by the DOH/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; food service establishments that are designed for single service 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 bed or
clients, other conditions and whether or not food service is provided. In the comments section, other details or conditions of
permitting/approval can be listed. At the 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 any validation that may be necessary.
Florida Department of Health/Bureau of Onsite Sewage Programs – March 2012
