Form DH 4012 Application for Septage Disposal Service Permit, Temporary System Service Permit, Septage Treatment and Disposal Facility, Septic Tank Manufacturing Approval - Florida

Form DH4012 or the "Application For Septage Disposal Service Permit, Temporary System Service Permit, Septage Treatment And Disposal Facility, Septic Tank Manufacturing Approval" is a form issued by the Florida Department of Health.

Download a PDF version of the Form DH4012 down below or find it on the Florida Department of Health Forms website.

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR
SEPTAGE DISPOSAL SERVICE PERMIT
TEMPORARY SYSTEM SERVICE PERMIT
SEPTAGE TREATMENT & DISPOSAL FACILITY
SEPTIC TANK MANUFACTURING APPROVAL
Authority:
Chapter 381, F.S.
Application/Permit Number:
Chapter 64E-6, F.A.C
Date:
/
/
Application is for:
Septage Disposal Service
Temporary System Service:
Septage Treatment Facility:
Septic Tank Manufacturing:
GENERAL INFORMATION
Business Name:
Phone Number:
Certificate of Authorization #
Contractor Registration #
Plumbing License #
Owner(s) Name:
Phone Number:
Business Location:
City:
County:
Mailing Address:
City:
State:
Zip:
SEPTAGE DISPOSAL SERVICES
Number of Vehicles to be Permitted:
Vehicle Identification Number/License Plate Number
Truck Gallonage Capacity
Counties of Operation
Inspected & Approved
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
List equipment used in the operation of this business necessary for the sanitary pumping, transport, and disposal of septage:
Disposal Method: Wastewater Treatment Plant:
Location:
Approved: Yes
No
Land Application Site:
Location:
Approved: Yes
No
Sanitary Landfill:
Location:
Approved: Yes
No
Owner/Operator of Disposal Site:
Are facilities available at the disposal site for the proper treatment and stabilization of septage and grease: Yes
No
If No, location where the waste will be stabilized:
By what method:
Facility will be under the regulation of DEP
DOH
Both
Directions to Disposal Site:
Provide a letter of authorization from the operator of the disposal site allowing your business to dispose of septage at that location. If restrictions have been placed
on your business by the operator of the disposal facility, the restrictions must be specified in the letter.
TEMPORARY SYSTEM SERVICES (INCLUDES PORTABLE TOILETS AND HOLDING TANKS)
Back up Service Available: Yes
No
If Yes, Name of Back Up Service:
Address:
Phone Number:
Truck Gallonage Capacity
Vehicle Identification Number/License Plate Number
(Waste/Water)
Counties of Operation
Inspected & Approved
Yes:
No:
Yes:
No:
Yes:
No:
Disposal Site:
Approved: Yes
No
Provide a letter of authorization from the operator of the disposal site allowing your business to dispose of portable toilet and/or holding tank wastes at that
location. If restrictions have been placed on your business by the operator of the disposal facility, the restrictions must be specified in the letter.
DH 4012, 01/92 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.010, FAC
Page 1 of 2
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR
SEPTAGE DISPOSAL SERVICE PERMIT
TEMPORARY SYSTEM SERVICE PERMIT
SEPTAGE TREATMENT & DISPOSAL FACILITY
SEPTIC TANK MANUFACTURING APPROVAL
Authority:
Chapter 381, F.S.
Application/Permit Number:
Chapter 64E-6, F.A.C
Date:
/
/
Application is for:
Septage Disposal Service
Temporary System Service:
Septage Treatment Facility:
Septic Tank Manufacturing:
GENERAL INFORMATION
Business Name:
Phone Number:
Certificate of Authorization #
Contractor Registration #
Plumbing License #
Owner(s) Name:
Phone Number:
Business Location:
City:
County:
Mailing Address:
City:
State:
Zip:
SEPTAGE DISPOSAL SERVICES
Number of Vehicles to be Permitted:
Vehicle Identification Number/License Plate Number
Truck Gallonage Capacity
Counties of Operation
Inspected & Approved
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
List equipment used in the operation of this business necessary for the sanitary pumping, transport, and disposal of septage:
Disposal Method: Wastewater Treatment Plant:
Location:
Approved: Yes
No
Land Application Site:
Location:
Approved: Yes
No
Sanitary Landfill:
Location:
Approved: Yes
No
Owner/Operator of Disposal Site:
Are facilities available at the disposal site for the proper treatment and stabilization of septage and grease: Yes
No
If No, location where the waste will be stabilized:
By what method:
Facility will be under the regulation of DEP
DOH
Both
Directions to Disposal Site:
Provide a letter of authorization from the operator of the disposal site allowing your business to dispose of septage at that location. If restrictions have been placed
on your business by the operator of the disposal facility, the restrictions must be specified in the letter.
TEMPORARY SYSTEM SERVICES (INCLUDES PORTABLE TOILETS AND HOLDING TANKS)
Back up Service Available: Yes
No
If Yes, Name of Back Up Service:
Address:
Phone Number:
Truck Gallonage Capacity
Vehicle Identification Number/License Plate Number
(Waste/Water)
Counties of Operation
Inspected & Approved
Yes:
No:
Yes:
No:
Yes:
No:
Disposal Site:
Approved: Yes
No
Provide a letter of authorization from the operator of the disposal site allowing your business to dispose of portable toilet and/or holding tank wastes at that
location. If restrictions have been placed on your business by the operator of the disposal facility, the restrictions must be specified in the letter.
DH 4012, 01/92 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.010, FAC
Page 1 of 2
SEPTAGE TREATMENT & DISPOSAL FACILITIES
Facility Owner(s):
Phone Number:
Facility Location:
County:
Directions to Facility:
Name of businesses using facility:
Business Name
Address
Phone #
Permit #
Methods of Treatment:
Maximum volume to be received daily:
Number of treatment receptacles at facility:
Volume of each receptacle:
gallons
Material used in construction: Concrete
Fiberglass
Other
gallons
If Other, describe:
gallons
gallons
Describe the treatment processes to be used:
Will treated septage be disposed of at this site: Yes
No
If yes, describe what equipment and methods will be
used for the removal and disposal of the treated material:
If no, provide the location where the treated material will ultimately be deposited:
Will other waste types be treated at this facility (example: Wastewater treatment plant residuals, portable toilet wastes, industrial
wastes, holding tank wastes, food establishment sludges, etc.): Yes
No
If yes, describe how they will be
segregated and handled:
Will this facility be operating under a permit from the Florida Department of Environmental Regulation: Yes
No
If yes, describe the permit and its conditions of operation (If no, an agricultural use plan must be prepared and submitted for
review and approval to the department prior to authorizing land application of treated septage)
SEPTIC TANK MANUFACTURING FACILITIES
Business Name:
Phone Number:
Owner(s) Name
Phone Number:
Business Location:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
Tank Size Requesting Approval:
Material Used
Reinforcing:
Tank Size Requesting Approval:
Material Used
Reinforcing:
Tank Size Requesting Approval:
Material Used
Reinforcing:
Tank Size Requesting Approval:
Material Used
Reinforcing:
Engineering Plans Submitted: Yes
No
Date Submitted:
/
/
Approval Granted: Yes
No
Signature of Applicant:
Date:
/
/
To be Completed by Health Unit:
Disapproved:
Date:
/
/
Reason:
Approved:
By:
Title:
CPHU Date:
/
/
(Circle as many as apply) Septage Disposal Service
Temporary System Service
Septage Treatment & Disposal Facility
Septic Tank Manufacturing Facility
DOH 4012, 01/92 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.010, FAC
Page 2 of 2

Download Form DH 4012 Application for Septage Disposal Service Permit, Temporary System Service Permit, Septage Treatment and Disposal Facility, Septic Tank Manufacturing Approval - Florida

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