Form DH4077 "Application for Certificate of Authorization" - Florida

Form DH4077 is a Florida Department of Health form also known as the "Application For Certificate Of Authorization". The latest edition of the form was released in April 1, 2003 and is available for digital filing.

Download an up-to-date Form DH4077 in PDF-format down below or look it up on the Florida Department of Health Forms website.

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Download Form DH4077 "Application for Certificate of Authorization" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR CERTIFICATE OF
AUTHORIZATION
FORWARD COMPLETED APPLICATION AND $250 FEE TO:
MAKE CORRECTIONS IN THE SPACES BELOW.
DOH, BUREAU OF ENVIRONMENTAL HEALTH
NOTIFY THE ONSITE SEWAGE PROGRAM
4052 BALD CYPRESS WAY, BIN# A08 TALLAHASSEE, FL 32399-1710
OFFICE WITHIN 30 DAYS OF ANY CHANGES.
BUSINESS
NAME
MAILING
ADDRESS
BUSINESS
ADDRESS
COUNTY
TELEPHONE
E-MAIL
ADDRESS
PLEASE CHECK EACH TYPE OF SEPTIC TANK CONTRACTING SERVICE YOU PROVIDE.
NEW SYSTEM INSTALLATIONS
SYSTEM MAINTENANCE
HOLDING TANK
SYSTEM REPAIRS
SEPTAGE DISPOSAL SERVICE
EXCAVATION / FILL HAULING
SYSTEM DESIGN
PORTABLE TOILET SERVICE
TANK ABANDONMENT
SITE EVALUATIONS
AEROBIC UNIT SERVICE
EXISTING SYSTEM INSPECTIONS
PLEASE LIST ALL PERSONNEL WHO ACT ON THE BUSINESS’S BEHALF AS SEPTIC TANK CONTRACTORS AND INDICATE THEIR POSITION
[PARTNER, ASSOCIATE, PRINCIPAL OFFICER, OWNER, EMPLOYEE] AS REGISTERED WITH THE DEPARTMENT OF STATE. ALL PERSONNEL
ACTING AS SEPTIC TANK CONTRACTORS MUST BE REGISTERED WITH THE DEPARTMENT OF HEALTH.
PLEASE LIST THE QUALIFYING CONTRACTOR FIRST.
CONTRACTOR’S NAME
REGISTRATION NUMBER
POSITION
I AFFIRM THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR DETERMINING
ELIGIBILITY FOR A SEPTIC TANK CONTRACTING CERTIFICATE OF AUTHORIZATION, IS TRUE.
I UNDERSTAND ANY
MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN THIS APPLICATION IS GROUNDS FOR AN ADMINISTRATIVE
FINE OR DENIAL OR REVOCATION OF MY SEPTIC CERTIFICATE OF AUTHORIZATION.
QUALIFYING CONTRACTOR’S SIGNATURE
DATE
FOR
Application Check No.
Authorization Number:
DCEH
Date of Application Check:
OFFICE
Check Amount:
Date Issued:
USE
Date of Approval: _____________________
ONLY
DH 4077, 04/03 (Obsoletes All Previous Editions) Incorporated: 64E-6.023, FAC
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR CERTIFICATE OF
AUTHORIZATION
FORWARD COMPLETED APPLICATION AND $250 FEE TO:
MAKE CORRECTIONS IN THE SPACES BELOW.
DOH, BUREAU OF ENVIRONMENTAL HEALTH
NOTIFY THE ONSITE SEWAGE PROGRAM
4052 BALD CYPRESS WAY, BIN# A08 TALLAHASSEE, FL 32399-1710
OFFICE WITHIN 30 DAYS OF ANY CHANGES.
BUSINESS
NAME
MAILING
ADDRESS
BUSINESS
ADDRESS
COUNTY
TELEPHONE
E-MAIL
ADDRESS
PLEASE CHECK EACH TYPE OF SEPTIC TANK CONTRACTING SERVICE YOU PROVIDE.
NEW SYSTEM INSTALLATIONS
SYSTEM MAINTENANCE
HOLDING TANK
SYSTEM REPAIRS
SEPTAGE DISPOSAL SERVICE
EXCAVATION / FILL HAULING
SYSTEM DESIGN
PORTABLE TOILET SERVICE
TANK ABANDONMENT
SITE EVALUATIONS
AEROBIC UNIT SERVICE
EXISTING SYSTEM INSPECTIONS
PLEASE LIST ALL PERSONNEL WHO ACT ON THE BUSINESS’S BEHALF AS SEPTIC TANK CONTRACTORS AND INDICATE THEIR POSITION
[PARTNER, ASSOCIATE, PRINCIPAL OFFICER, OWNER, EMPLOYEE] AS REGISTERED WITH THE DEPARTMENT OF STATE. ALL PERSONNEL
ACTING AS SEPTIC TANK CONTRACTORS MUST BE REGISTERED WITH THE DEPARTMENT OF HEALTH.
PLEASE LIST THE QUALIFYING CONTRACTOR FIRST.
CONTRACTOR’S NAME
REGISTRATION NUMBER
POSITION
I AFFIRM THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR DETERMINING
ELIGIBILITY FOR A SEPTIC TANK CONTRACTING CERTIFICATE OF AUTHORIZATION, IS TRUE.
I UNDERSTAND ANY
MISREPRESENTATION OR CONCEALMENT OF MATERIAL FACTS IN THIS APPLICATION IS GROUNDS FOR AN ADMINISTRATIVE
FINE OR DENIAL OR REVOCATION OF MY SEPTIC CERTIFICATE OF AUTHORIZATION.
QUALIFYING CONTRACTOR’S SIGNATURE
DATE
FOR
Application Check No.
Authorization Number:
DCEH
Date of Application Check:
OFFICE
Check Amount:
Date Issued:
USE
Date of Approval: _____________________
ONLY
DH 4077, 04/03 (Obsoletes All Previous Editions) Incorporated: 64E-6.023, FAC
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