Form DH4081 "Application for Onsite Sewage Treatment and Disposal System Operating Permit" - Florida

What Is Form DH4081?

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 October 1, 1996;
  • 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;

Download a printable version of Form DH4081 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4081 "Application for Onsite Sewage Treatment and Disposal System Operating Permit" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM OPERATING PERMIT
Authority: Chapter 381, F.S. & Chapter 64E-6, F.A.C.
Application/Permit Number
New:
Amended:
Renewal:
Aerobic:
Commercial:
Industrial/Manufacturing:
GENERAL INFORMATION
Property Owner
Work Telephone
Home phone:
Address of Owner:
City:
State
Zip
Owner's Agent:
Agent's Address:
City:
State
Zip
Agent's Phone:
Property Street Address:
City:
State
Zip
Section:
Township:
Range:
Parcel:
Lot:
Block:
Subdivision:
Unit:
EXISTING SYSTEM INFORMATION
Please complete those items shown below which are applicable to the existing permitted onsite sewage disposal system serving
the above referenced property: Onsite Sewage Treatment and Disposal System Construction Permit Number (if known):
Septic Tank(s)/Aerobic Unit
gallons
Grease Trap(s)
gallons
Dosing Tank
gallons
Drainfield size is
square feet installed in a: standard subsurface
filled
mound system
The drainfield layout is in trenches
absorption bed
other
(describe)
Onsite Well? Yes
No
System Setback to Wells
ft.
Lot Size
Square Feet
Estimated sewage flow into system
Gallons/Day
Based on
Number of businesses or dwellings (circle one) which are being served by this onsite sewage disposal system
Additional Comments:
COMMERCIAL/INDUSTRIAL/MANUFACTURING FACILITY
Please attach a business survey form for each business which is or will be served by the onsite sewage disposal system. Briefly
describe the type of activities that will be supported by the onsite sewage system serving this property.
What is the zoning designation for the property?
Give a description of the zoning and examples of
approved businesses in this type of zoning:
AEROBIC TREATMENT UNIT
Date of aerobic system installation approval:
/
/
Is the aerobic treatment unit still under the
manufacturer's initial two year warranty? Yes
No
Aerobic Unit Manufacturer:
Type of Aerobic Unit:
Class I:
Class II:
Above 1500 Gallon Capacity:
Construction/Installation Permit Number:
Are multiple aerobic units used on the site: Yes
No
Is there an active service agreement on the aerobic treatment unit? Yes
No
Please Attach a Copy of the Agreement
If yes, when does the service agreement expire?
/
/
Who is the authorized service company providing maintenance to your unit?
Company Name
Phone Number
Address
City
State
Zip
I hereby certify that the above information is accurate and a reflection of the actual conditions existing on the above referenced property. I understand that any
change of occupancy or tenancy at the above location will require me to file an amendment to this operating permit.
Applicant's signature:
Date
/
/
Application Status:
Disapproved:
Date
/
/
Reason:
By:
Title:
CHD
Approved:
Date
/
/
By:
Title:
CHD
DH 4081, 10/96 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.003, FAC
Page 1 of
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM OPERATING PERMIT
Authority: Chapter 381, F.S. & Chapter 64E-6, F.A.C.
Application/Permit Number
New:
Amended:
Renewal:
Aerobic:
Commercial:
Industrial/Manufacturing:
GENERAL INFORMATION
Property Owner
Work Telephone
Home phone:
Address of Owner:
City:
State
Zip
Owner's Agent:
Agent's Address:
City:
State
Zip
Agent's Phone:
Property Street Address:
City:
State
Zip
Section:
Township:
Range:
Parcel:
Lot:
Block:
Subdivision:
Unit:
EXISTING SYSTEM INFORMATION
Please complete those items shown below which are applicable to the existing permitted onsite sewage disposal system serving
the above referenced property: Onsite Sewage Treatment and Disposal System Construction Permit Number (if known):
Septic Tank(s)/Aerobic Unit
gallons
Grease Trap(s)
gallons
Dosing Tank
gallons
Drainfield size is
square feet installed in a: standard subsurface
filled
mound system
The drainfield layout is in trenches
absorption bed
other
(describe)
Onsite Well? Yes
No
System Setback to Wells
ft.
Lot Size
Square Feet
Estimated sewage flow into system
Gallons/Day
Based on
Number of businesses or dwellings (circle one) which are being served by this onsite sewage disposal system
Additional Comments:
COMMERCIAL/INDUSTRIAL/MANUFACTURING FACILITY
Please attach a business survey form for each business which is or will be served by the onsite sewage disposal system. Briefly
describe the type of activities that will be supported by the onsite sewage system serving this property.
What is the zoning designation for the property?
Give a description of the zoning and examples of
approved businesses in this type of zoning:
AEROBIC TREATMENT UNIT
Date of aerobic system installation approval:
/
/
Is the aerobic treatment unit still under the
manufacturer's initial two year warranty? Yes
No
Aerobic Unit Manufacturer:
Type of Aerobic Unit:
Class I:
Class II:
Above 1500 Gallon Capacity:
Construction/Installation Permit Number:
Are multiple aerobic units used on the site: Yes
No
Is there an active service agreement on the aerobic treatment unit? Yes
No
Please Attach a Copy of the Agreement
If yes, when does the service agreement expire?
/
/
Who is the authorized service company providing maintenance to your unit?
Company Name
Phone Number
Address
City
State
Zip
I hereby certify that the above information is accurate and a reflection of the actual conditions existing on the above referenced property. I understand that any
change of occupancy or tenancy at the above location will require me to file an amendment to this operating permit.
Applicant's signature:
Date
/
/
Application Status:
Disapproved:
Date
/
/
Reason:
By:
Title:
CHD
Approved:
Date
/
/
By:
Title:
CHD
DH 4081, 10/96 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.003, FAC
Page 1 of
BUSINESS SURVEY
AN ATTACHMENT TO DH 4081
ASSESSMENT OF WASTE HANDLING AND BUSINESS ACTIVITIES
New:
Application/Permit Number
Renewal:
Change of Tenancy/Amendment:
Please provide the following information regarding your business facilities and the activities which will take place on site.
Business Name
Occupational License #:
Business Owner's Name
Business Mailing Address
Telephone
City
State
Zip
Street Address of Business
Unit Number
City
State
Zip
How many employees will use this facility
Hours of operation
What type and number of sanitary facilities will be available at this location:
Anticipated flow:
gpd Based on
Toilets
Urinals
Hand Washing Sinks
Utility Sinks
Showers
Floor Drains
Equipment Drains(Describe)
2-Compartment Sinks
3-Compartment Sinks
Laundry Facilities
Garbage Grinder/Disposal
Commercial Dish Machines (heat sanitizing)
(chemical sanitizing)
Can Washing Facilities
Other(Describe)
Completely describe the activities which will take place at your business location (i.e. types of waste generated, volume of raw
materials handled, amount of wastes generated, equipment used in the process):
List any chemical compounds routinely used in your business: Attach Material Safety Data Sheets for Compounds Used or
Stored
Name
Gal or lbs./Month
Amt. on hand
Storage Method
Disposal Method
SIC Code
Please list licensed waste haulers removing wastes from your site.
Company Name
Type of Waste Removed
Describe how emergencies, such as spills, will be handled at this site:
As the business owner, I understand that information contained in this application serves as a basis for determining the suitability of the onsite sewage disposal
system to serve the business described above. Information contained herein is an accurate reflection of the activities which will be allowed on this site. I also
agree to perform any testing as may be required by this permit, and collection & analysis of samples will be done at my own expense by a state certified laboratory.
I also agree to notify the county health department of the change in any material fact used to determine the issuance of this permit.
Business Owner or Agent's Signature:
Date
Property Owner or Agent's Signature:
Date
TO BE COMPLETED BY COUNTY HEALTH DEPARTMENT:
Will monitoring be required: Yes
No
Sample location
Compounds to be examined:
Is DER/ County Haz Waste review required: Yes
No
Monitoring Frequency
Survey disapproved
Date:
/
/
Reason
Survey approved:
By:
Title
CHD Date:
/
/
DH 4081A, 10/96 (Obsoletes previous editions which may not be used) Incorporated: 64E-6.003, FAC
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