Form DH4015 "Onsite Sewage Treatment and Disposal System Existing System and System Repair Evaluation" - Florida

What Is Form DH4015?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on August 1, 2009;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
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Download a fillable version of Form DH4015 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4015 "Onsite Sewage Treatment and Disposal System Existing System and System Repair Evaluation" - Florida

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STATE OF FLORIDA
PERMIT #
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
APPLICANT:
CONTRACTOR / AGENT
CONTRACTOR / AGENT:
LOT:
BLOCK:
SUBDIV:
ID#:
================================================================================================
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR
OTHER CERTIFIED PERSON.
SIGN AND SEAL ALL SUBMITTED DOCUMENTS.
COMPLETE ALL APPLICABLE ITEMS.
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
================================================================================================
EXISTING TANK INFORMATION
GALLONS SEPTIC TANK / GPD ATU
Y / N
[
] GALLONS SEPTIC TANK/GPD ATU
LEGEND:
MATERIAL:
BAFFLED:[Y / N]
GALLONS SEPTIC TANK / GPD ATU
Y / N
[
] GALLONS SEPTIC TANK/GPD ATU
LEGEND:
MATERIAL:
BAFFLED:[Y / N]
[
] GALLONS GREASE INTERCEPTOR
LEGEND:
MATERIAL:
[
] GALLONS DOSING TANK
LEGEND:
MATERIAL:
# PUMPS:[
]
================================================================================================
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON
/
/
BY
, HAVE
DIMENSIONS / FILLING / LEGEND
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS / FILLING / LEGEND ], ARE FREE OF OBSERVABLE
SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE
DEFECTS OR LEAKS, AND HAVE A [ SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE ] INSTALLED.
SIGNATURE OF LICENSED CONTRACTOR
BUSINESS NAME
DATE
================================================================================================
EXISTING DRAINFIELD INFORMATION
[
] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
NO. OF TRENCHES [
]
DIMENSIONS:
X
[
] SQUARE FEET
SYSTEM
NO. OF TRENCHES [
]
DIMENSIONS:
X
TYPE OF SYSTEM:
[
] STANDARD
[
] FILLED
[
] MOUND
[
]
CONFIGURATION:
[
] TRENCH
[
] BED
[
]
DESIGN:
[
] HEADER
[
] D-BOX
[
] GRAVITY SYSTEM
[
] DOSED SYSTEM
ABOVE / BELOW
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE
INCHES [ ABOVE / BELOW]
SYSTEM FAILURE AND REPAIR INFORMATION
[
] SYSTEM INSTALLATION DATE
TYPE OF WASTE
[
] DOMESTIC
[
] COMMERCIAL
[
] GPD ESTIMATED SEWAGE FLOW BASED ON
[
] METERED WATER
[
] TABLE 1, 64E-6, FAC
SITE
[
] DRAINAGE STRUCTURES
[
] POOL
[
] PATIO / DECK
[
] PARKING
CONDITIONS: [
] SLOPING PROPERTY
[
]
NATURE OF
[
] HYDRAULIC OVERLOAD
[
] SOILS
[
] MAINTENANCE
[
] SYSTEM DAMAGE
FAILURE:
[
] DRAINAGE / RUN OFF
[
] ROOTS
[
] WATER TABLE
[
]
FAILURE
[
] SEWAGE ON GROUND
[
] TANK
[
] D BOX/HEADER
[
] DRAINFIELD
SYMPTOM:
[
] PLUMBING BACKUP
[
]
REMARKS/ADDITIONAL CRITERIA
SUBMITTED BY:
TITLE/LICENSE
DATE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
Page 4 of 4
STATE OF FLORIDA
PERMIT #
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION
APPLICANT:
CONTRACTOR / AGENT
CONTRACTOR / AGENT:
LOT:
BLOCK:
SUBDIV:
ID#:
================================================================================================
TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR
OTHER CERTIFIED PERSON.
SIGN AND SEAL ALL SUBMITTED DOCUMENTS.
COMPLETE ALL APPLICABLE ITEMS.
COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.
================================================================================================
EXISTING TANK INFORMATION
GALLONS SEPTIC TANK / GPD ATU
Y / N
[
] GALLONS SEPTIC TANK/GPD ATU
LEGEND:
MATERIAL:
BAFFLED:[Y / N]
GALLONS SEPTIC TANK / GPD ATU
Y / N
[
] GALLONS SEPTIC TANK/GPD ATU
LEGEND:
MATERIAL:
BAFFLED:[Y / N]
[
] GALLONS GREASE INTERCEPTOR
LEGEND:
MATERIAL:
[
] GALLONS DOSING TANK
LEGEND:
MATERIAL:
# PUMPS:[
]
================================================================================================
I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON
/
/
BY
, HAVE
DIMENSIONS / FILLING / LEGEND
THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS / FILLING / LEGEND ], ARE FREE OF OBSERVABLE
SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE
DEFECTS OR LEAKS, AND HAVE A [ SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE ] INSTALLED.
SIGNATURE OF LICENSED CONTRACTOR
BUSINESS NAME
DATE
================================================================================================
EXISTING DRAINFIELD INFORMATION
[
] SQUARE FEET PRIMARY DRAINFIELD SYSTEM
NO. OF TRENCHES [
]
DIMENSIONS:
X
[
] SQUARE FEET
SYSTEM
NO. OF TRENCHES [
]
DIMENSIONS:
X
TYPE OF SYSTEM:
[
] STANDARD
[
] FILLED
[
] MOUND
[
]
CONFIGURATION:
[
] TRENCH
[
] BED
[
]
DESIGN:
[
] HEADER
[
] D-BOX
[
] GRAVITY SYSTEM
[
] DOSED SYSTEM
ABOVE / BELOW
ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE
INCHES [ ABOVE / BELOW]
SYSTEM FAILURE AND REPAIR INFORMATION
[
] SYSTEM INSTALLATION DATE
TYPE OF WASTE
[
] DOMESTIC
[
] COMMERCIAL
[
] GPD ESTIMATED SEWAGE FLOW BASED ON
[
] METERED WATER
[
] TABLE 1, 64E-6, FAC
SITE
[
] DRAINAGE STRUCTURES
[
] POOL
[
] PATIO / DECK
[
] PARKING
CONDITIONS: [
] SLOPING PROPERTY
[
]
NATURE OF
[
] HYDRAULIC OVERLOAD
[
] SOILS
[
] MAINTENANCE
[
] SYSTEM DAMAGE
FAILURE:
[
] DRAINAGE / RUN OFF
[
] ROOTS
[
] WATER TABLE
[
]
FAILURE
[
] SEWAGE ON GROUND
[
] TANK
[
] D BOX/HEADER
[
] DRAINFIELD
SYMPTOM:
[
] PLUMBING BACKUP
[
]
REMARKS/ADDITIONAL CRITERIA
SUBMITTED BY:
TITLE/LICENSE
DATE:
DH 4015, 08/09 (Obsoletes previous editions which may not be used)
Incorporated 64E-6.001, FAC
Page 4 of 4
INSTRUCTIONS:
PERMIT #
Permit tracking number assigned by department
APPLICANT
Property owner’s full name
CONTRACTOR/AGENT
Licensed contractor or property owner’s legal agent
LOT,BLOCK,SUBDIVISION
Legal description for property
ID #
Property appraiser identification number for property
EXISTING TANK
TANK 1
Complete tank size in gallons or gpd and mark appropriately.
Complete LEGEND (SHO approval number), MATERIAL (concrete, fiberglass,
polyethylene) and whether or not tank in BAFFLED.
TANK 2
Same as TANK 1.
GREASE INTERCEPTOR
Same as TANK 1.
DOSING TANK
Same as TANK 1. Complete # PUMPS installed.
TANK CERTIFICATION
Completed by registered septic tank contractor, state-licensed plumber, certified EH
professional, or master septic tank contractor. Show the date the tanks were pumped, the
name of the pumping company, how the tank volumes were determined (measurement of
tank dimensions and calculation of volume, filling the tank from a metered water source,
or recording the tank legend for known tanks). If tank dimensions are used, list the tank
dimensions in the remarks section. Indicate whether the tank has a solids deflection
device or an outletlet filter. If the tanks cannot be certified, note that fact in the remarks
section.
EXISTING DRAINFIELD
FIELD 1
Complete size of drainfield in square feet, NO. OF TRENCHES (if applicable) and
DIMENSION (bed width and length or trench width and total length of trenches).
FIELD 2
Same as FIELD 1
TYPE OF SYSTEM
Mark appropriate block
CONFIGURATION
Mark appropriate block
DESIGN
Mark appropriate blocks
ELEVATION
Record elevation of lowest point of bottom of drainfield in reference to natural grade
FAILURE / REPAIR INFORMATION
INSTALLATION DATE
Record year of original system installation
TYPE OF WASTE
Mark appropriate block
GPD
Provide estimated sewage flow to system based on metered water flow data (if available)
or Table 1, whichever is greater.
SITE CONDITIONS
Mark all applicable blocks. Record any other significant conditions.
NATURE OF FAILURE
Mark all applicable blocks.
FAILURE SYMPTOM
Mark all applicable blocks.
REMARKS
Record any other significant criteria that may impact system design. If dimensions are
used to determine tank volumes, list the tank dimensions in the remarks section. If the
tanks cannot be certified as free of observable defects or leaks, explain in remarks.
SUBMITTED BY
Signature of person performing evaluation
TITLE/LICENSE
Title of department person or license number of other evaluators.
DATE
Date of evaluation.
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