Form DH4016 "System Repair Certification - Onsite Sewage Treatment and Disposal System" - Florida

What Is Form DH4016?

This is a legal form that was released by the Florida Department of Health - 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 Health;
  • 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 fillable version of Form DH4016 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4016 "System Repair Certification - Onsite Sewage Treatment and Disposal System" - Florida

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PERMIT #
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SYSTEM REPAIR CERTIFICATION
APPLICANT:
MST CONTRACTOR:
REGISTRATION NO. SM
PROPERTY STREET ADDRESS:
LOT:
BLOCK:
SUBDIV:
ID#:
COMPLETE ALL APPLICABLE ITEMS.
DRAW AS-BUILT SYSTEM AND RECORD ELEVATION MARKS ON BACK OF FORM.
TANK 1: NEW [ ]
SIZE
MATERIAL
LEGEND
OUTLET FILTER [ ]
TANK 2: NEW [ ]
SIZE
MATERIAL
LEGEND
OUTLET FILTER [ ]
GREASE
NEW [ ]
SIZE
MATERIAL
LEGEND
TRAP:
NEW [ ]
SIZE
MATERIAL
LEGEND
DOSING
NEW [ ]
SIZE
MATERIAL
LEGEND
TANK:
PUMPS:
NEW [
]
# PUMPS:
MAKE AND MODEL NO.
DOSING
NEW [ ]
SIZE
MATERIAL
LEGEND
TANK:
PUMPS:
NEW [
]
# PUMPS:
MAKE AND MODEL NO.
FIELD 1:
SIZE
# PIPES
# TRENCHES
BED
X
[ D BOX / HEADER ]
D BOX / HEADER
NEW [
]
ELEVATION OF BOTTOM OF DRAINFIELD
[IN / FT] [ABOVE / BELOW] BENCHMARK/REF POINT
IN/FT
ABOVE/BELOW
FIELD 2:
SIZE
# PIPES
# TRENCHES
BED
X
[ D BOX / HEADER ]
D BOX / HEADER
NEW [
]
ELEVATION OF BOTTOM OF DRAINFIELD
[IN / FT] [ ABOVE/BELOW ] BENCHMARK/REF POINT
IN/FT
ABOVE/BELOW
AGGREGATE:
SIZE:
SOURCE:
FILL:
AMOUNT:
INCHES
TEXTURE:
EXCAVATION: DEPTH:
INCHES
TEXTURE:
FILLED/MOUND SYSTEM STABILIZATION DATE:
/
/
MATERIAL:
SETBACKS:
SURFACE WATER:
DITCHES:
FOUNDATION:
PROPERTY LINE:
[IN FEET]
WELLS: PRIVATE:
PUBLIC:
IRRIGATION:
WATER LINES:
ABANDONMENT:
TANK PUMPED:
/
/
TANK CRUSHED AND FILLED: ______/_____/
BY:
REGISTRATION NO:
REMARKS [DESCRIBE ANY REPAIRS OR MODIFICATIONS TO EXISTING SYSTEM]:
THIS IS TO CERTIFY THAT I HAVE PERSONALLY INSPECTED THE ABOVE REFERENCED ONSITE SEWAGE TREATMENT
AND DISPOSAL SYSTEM INSTALLATION. THE SYSTEM INSTALLED IS IN FULL COMPLIANCE WITH THE PERMIT AND
S. 381.0065, FLORIDA STATUTES, AND CHAPTER 64E-6, FLORIDA ADMINISTRATIVE CODE.
I UNDERSTAND THAT FALSIFICATION OF THIS REPORT IS GROUNDS FOR IMPOSITION OF AN ADMINISTRATIVE
FINE OR SUSPENSION OR REVOCATION OF MY SEPTIC TANK CONTRACTING REGISTRATION AND AUTHORIZATION.
SIGNATURE:
DATE:
DH 4016, 08/09
(Obsoletes previous editions which may not be used)
Incorporated:
64E-6.001, FAC
Page 3 of 3
PERMIT #
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
SYSTEM REPAIR CERTIFICATION
APPLICANT:
MST CONTRACTOR:
REGISTRATION NO. SM
PROPERTY STREET ADDRESS:
LOT:
BLOCK:
SUBDIV:
ID#:
COMPLETE ALL APPLICABLE ITEMS.
DRAW AS-BUILT SYSTEM AND RECORD ELEVATION MARKS ON BACK OF FORM.
TANK 1: NEW [ ]
SIZE
MATERIAL
LEGEND
OUTLET FILTER [ ]
TANK 2: NEW [ ]
SIZE
MATERIAL
LEGEND
OUTLET FILTER [ ]
GREASE
NEW [ ]
SIZE
MATERIAL
LEGEND
TRAP:
NEW [ ]
SIZE
MATERIAL
LEGEND
DOSING
NEW [ ]
SIZE
MATERIAL
LEGEND
TANK:
PUMPS:
NEW [
]
# PUMPS:
MAKE AND MODEL NO.
DOSING
NEW [ ]
SIZE
MATERIAL
LEGEND
TANK:
PUMPS:
NEW [
]
# PUMPS:
MAKE AND MODEL NO.
FIELD 1:
SIZE
# PIPES
# TRENCHES
BED
X
[ D BOX / HEADER ]
D BOX / HEADER
NEW [
]
ELEVATION OF BOTTOM OF DRAINFIELD
[IN / FT] [ABOVE / BELOW] BENCHMARK/REF POINT
IN/FT
ABOVE/BELOW
FIELD 2:
SIZE
# PIPES
# TRENCHES
BED
X
[ D BOX / HEADER ]
D BOX / HEADER
NEW [
]
ELEVATION OF BOTTOM OF DRAINFIELD
[IN / FT] [ ABOVE/BELOW ] BENCHMARK/REF POINT
IN/FT
ABOVE/BELOW
AGGREGATE:
SIZE:
SOURCE:
FILL:
AMOUNT:
INCHES
TEXTURE:
EXCAVATION: DEPTH:
INCHES
TEXTURE:
FILLED/MOUND SYSTEM STABILIZATION DATE:
/
/
MATERIAL:
SETBACKS:
SURFACE WATER:
DITCHES:
FOUNDATION:
PROPERTY LINE:
[IN FEET]
WELLS: PRIVATE:
PUBLIC:
IRRIGATION:
WATER LINES:
ABANDONMENT:
TANK PUMPED:
/
/
TANK CRUSHED AND FILLED: ______/_____/
BY:
REGISTRATION NO:
REMARKS [DESCRIBE ANY REPAIRS OR MODIFICATIONS TO EXISTING SYSTEM]:
THIS IS TO CERTIFY THAT I HAVE PERSONALLY INSPECTED THE ABOVE REFERENCED ONSITE SEWAGE TREATMENT
AND DISPOSAL SYSTEM INSTALLATION. THE SYSTEM INSTALLED IS IN FULL COMPLIANCE WITH THE PERMIT AND
S. 381.0065, FLORIDA STATUTES, AND CHAPTER 64E-6, FLORIDA ADMINISTRATIVE CODE.
I UNDERSTAND THAT FALSIFICATION OF THIS REPORT IS GROUNDS FOR IMPOSITION OF AN ADMINISTRATIVE
FINE OR SUSPENSION OR REVOCATION OF MY SEPTIC TANK CONTRACTING REGISTRATION AND AUTHORIZATION.
SIGNATURE:
DATE:
DH 4016, 08/09
(Obsoletes previous editions which may not be used)
Incorporated:
64E-6.001, FAC
Page 3 of 3
AS BUILT INSTALLATION SKETCH
INSTRUCTIONS:
PERMIT # : Permit tracking number assigned by Health Department.
SYSTEM ELEVATION SURVEY
APPLICANT Property owner's full name.
MST CONTRACTOR: Master Septic Tank Contractor performing certification.
BENCHMARK:
REGISTRATION NO: Master Septic Tank Contractor registration number.
NATURAL GRADE:
PROPERTY STREET ADDRESS: Street address and locale of installation.
LOT/BLOCK/SUBDIVISION/ID#: Property appraiser lot identification.
TANK INLET:
TANK1: Complete all information on new and existing tanks. Indicate if Tank is NEW or leave
TANK OUTLET:
blank for existing. Complete SIZE (gallons), MATERIAL (concrete, fiberglass, polyethylene),
TOP OF TANK:
LEGEND (SHO Approval No.). Mark OUTLET FILTER if installed - leave blank if NA.
TANK2: Same as TANK1.
TANK INLET:
GREASE TRAP: Same as TANK1.
TANK OUTLET:
DOSING TANK: Same as TANK1. Complete information on new and existing pumps indicating
TOP OF TANK:
if pumps are NEW (leave blank for existing), # PUMPS, and MAKE AND MODEL NO.
FIELD 1: Complete all information on new and existing drainfields. Indicate if NEW field or
DRAINFIELD: Indicate in as-built sketch
leave blank for existing. Complete SIZE (square feet), # PIPES, # TRENCHES (leave blank if
TOP
DEPTH
BOTTOM
NA), DIMENSIONS (width and bed length or total length of all trenches), D BOX/HEADER
AGGREGATE
(circle applicable item), ELEVATION (elevation of lowest point of bottom of drainfield in
A
relation to benchmark or reference point).
B
FIELD 2: Same as FIELD1.
C
AGGREGATE: Complete all items indicating SIZE and SOURCE from bill of lading.
D
FILL: Complete if applicable indicating AMOUNT of fill in inches from natural grade and USDA
E
soil TEXTURE.
F
EXCAVATION: Complete if applicable indicating DEPTH of excavation in inches an USDA
G
soil TEXTURE of replacement material.
H
FILLED/MOUND SYSTEM STABILIZATION: Complete if applicable DATE and MATERIAL.
SETBACKS: Complete all items indicating NA if not applicable. Actual measurements in feet
for all applicable items.
ABANDONMENT: Complete if applicable indicating date TANK PUMPED and date TANK
CRUSHED AND FILLED and name and registration number of permitted septage disposal
company pumping tank.
REMARKS: Describe any repairs or modifications to existing system or other site specific
information.
SIGNATURE: Signature of Master Septic Tank Contractor performing certification.
DATE: Date of Certification.
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