Form DH4075 "Application for Septic Tank Contractor Registration" - Florida

What Is Form DH4075?

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 January 1, 1997;
  • 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 DH4075 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form DH4075 "Application for Septic Tank Contractor Registration" - Florida

1172 times
Rate (4.8 / 5) 82 votes
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTOR
REGISTRATION
FORWARD COMPLETED APPLICATION WITH REQUIRED STATEMENTS, EMPLOYMENT DOCUMENTATION AND $75.00 FEE TO: DEPARTMENT OF HEALTH,
BUREAU OF ENVIRONMENTAL HEALTH, 4052 BALD CYPRESS WAY, BIN #A08, TALLAHASSEE, FL 32399-1710
SECTION I: PERSONAL INFORMATION
NAME OF APPLICANT ________________________________________________________________________________________
LAST
FIRST
MI
DATE OF BIRTH ______ / ______ / ______ EMAIL ADDRESS_____________________________________________________
MM
DD
YY
BUSINESS NAME _____________________________________________________ TELEPHONE (______)__________________
MAILING ADDRESS __________________________________________________________________________________________
STREET/PO BOX
CITY
COUNTY
STATE
ZIP
PLEASE CHECK EACH TYPE OF SERVICE YOU INTEND TO PROVIDE AS A SEPTIC TANK CONTRACTOR.
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
SECTION II: EMPLOYMENT HISTORY
COMPLETE ATTACHMENT 1 DOCUMENTING THE MOST RECENT 25 CONTRACTS COMPLETED IMMEDIATELY PRECEDING THE DATE OF
FILING. ATTACH (1) TWO SIGNED STATEMENTS FROM PERSONS FOR WHOM YOU HAVE PROVIDED SERVICES IN THE ONSITE SEWAGE
INDUSTRY STATING WHAT SERVICES WERE PROVIDED. (2) CERTIFICATION FROM A REGISTERED SEPTIC TANK CONTRACTOR OR
PLUMBING CONTRACTOR OF EMPLOYMENT DATES AND WORK RESPONSIBILITIES.(3) DOCUMENTATION OF FEDERAL WITHHOLDING,
SOCIAL SECURITY, AND WORKER’S COMPENSATION PAYMENT.
1.
BUSINESS NAME ________________________________________________________________________________________
SUPERVISOR’S NAME AND LICENSE NUMBER ____________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________________________
DATES OF EMPLOYMENT _____ / _____ / _____ TO _____ / _____ / _____ TELEPHONE _________________________
WORK RESPONSIBILITIES _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2.
BUSINESS NAME ________________________________________________________________________________________
SUPERVISOR’S NAME AND LICENSE NUMBER ____________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________________________
DATES OF EMPLOYMENT _____ / _____ / _____ TO _____ / _____ / _____ TELEPHONE _________________________
WORK RESPONSIBILITIES _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3.
BUSINESS NAME ________________________________________________________________________________________
SUPERVISOR’S NAME AND LICENSE NUMBER ____________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________________________
DATES OF EMPLOYMENT _____ / _____ / _____ TO _____ / _____ / _____ TELEPHONE _________________________
WORK RESPONSIBILITIES _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CONTINUED ON REVERSE
DH 4075, 1/97 (Obsoletes All Previous Editions) Incorporated: 64E-6.019, FAC
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTOR
REGISTRATION
FORWARD COMPLETED APPLICATION WITH REQUIRED STATEMENTS, EMPLOYMENT DOCUMENTATION AND $75.00 FEE TO: DEPARTMENT OF HEALTH,
BUREAU OF ENVIRONMENTAL HEALTH, 4052 BALD CYPRESS WAY, BIN #A08, TALLAHASSEE, FL 32399-1710
SECTION I: PERSONAL INFORMATION
NAME OF APPLICANT ________________________________________________________________________________________
LAST
FIRST
MI
DATE OF BIRTH ______ / ______ / ______ EMAIL ADDRESS_____________________________________________________
MM
DD
YY
BUSINESS NAME _____________________________________________________ TELEPHONE (______)__________________
MAILING ADDRESS __________________________________________________________________________________________
STREET/PO BOX
CITY
COUNTY
STATE
ZIP
PLEASE CHECK EACH TYPE OF SERVICE YOU INTEND TO PROVIDE AS A SEPTIC TANK CONTRACTOR.
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
SECTION II: EMPLOYMENT HISTORY
COMPLETE ATTACHMENT 1 DOCUMENTING THE MOST RECENT 25 CONTRACTS COMPLETED IMMEDIATELY PRECEDING THE DATE OF
FILING. ATTACH (1) TWO SIGNED STATEMENTS FROM PERSONS FOR WHOM YOU HAVE PROVIDED SERVICES IN THE ONSITE SEWAGE
INDUSTRY STATING WHAT SERVICES WERE PROVIDED. (2) CERTIFICATION FROM A REGISTERED SEPTIC TANK CONTRACTOR OR
PLUMBING CONTRACTOR OF EMPLOYMENT DATES AND WORK RESPONSIBILITIES.(3) DOCUMENTATION OF FEDERAL WITHHOLDING,
SOCIAL SECURITY, AND WORKER’S COMPENSATION PAYMENT.
1.
BUSINESS NAME ________________________________________________________________________________________
SUPERVISOR’S NAME AND LICENSE NUMBER ____________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________________________
DATES OF EMPLOYMENT _____ / _____ / _____ TO _____ / _____ / _____ TELEPHONE _________________________
WORK RESPONSIBILITIES _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2.
BUSINESS NAME ________________________________________________________________________________________
SUPERVISOR’S NAME AND LICENSE NUMBER ____________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________________________
DATES OF EMPLOYMENT _____ / _____ / _____ TO _____ / _____ / _____ TELEPHONE _________________________
WORK RESPONSIBILITIES _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3.
BUSINESS NAME ________________________________________________________________________________________
SUPERVISOR’S NAME AND LICENSE NUMBER ____________________________________________________________
BUSINESS ADDRESS _____________________________________________________________________________________
DATES OF EMPLOYMENT _____ / _____ / _____ TO _____ / _____ / _____ TELEPHONE _________________________
WORK RESPONSIBILITIES _______________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CONTINUED ON REVERSE
DH 4075, 1/97 (Obsoletes All Previous Editions) Incorporated: 64E-6.019, FAC
SECTION III: MORAL CHARACTER
PLEASE ANSWER EACH QUESTION. IF YOU ANSWER “YES” TO ANY QUESTION, PLEASE ATTACH A
YES
NO
STATEMENT AND DOCUMENTATION EXPLAINING YOUR ANSWER.
HAVE YOU BEEN CONVICTED OR FOUND GUILTY OF, OR ENTERED A PLEA OF NOLO
CONTENDERE TO, REGARDLESS OF ADJUDICATION, FOR A CRIME IN ANY JURISDICTION?
DO YOU HAVE A DISCIPLINARY CASE OR ADMINISTRATIVE PENALTY PENDING WITH THE
DEPARTMENT INVOLVING SEPTIC TANK CONTRACTING?
HAVE YOU BEEN CONVICTED OF A CRIME IN ANY JURISDICTION RELATING TO SEPTIC TANK
CONTRACTING DURING THE LAST TWELVE MONTHS?
HAVE YOU HAD A SEPTIC TANK CONTRACTING REGISTRATION REVOKED WITHIN THE LAST
FIVE YEARS?
I AFFIRM THE INFORMATION CONTAINED IN THIS APPLICATION, WHICH SERVES AS THE BASIS FOR
DETERMINING MY ELIGIBILITY FOR SEPTIC TANK CONTRACTOR REGISTRATION, 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 TANK CONTRACTOR REGISTRATION.
APPLICANT’S SIGNATURE
DATE ________________________
SECTION IV: REGULATORY REVIEW
APPLICATION MUST BE REVIEWED BY THE COUNTY HEALTH DEPARTMENT FOR THE COUNTY IN WHICH YOUR BUSINESS IS LOCATED.
IF THE COUNTY HEALTH DEPARTMENT HAS NOT REGULATED YOUR WORK, ATTACH A LETTER FROM THE GOVERNMENT AGENCY
WHICH REGULATED YOUR WORK, IN ADDITION TO THE COUNTY HEALTH DEPARTMENT REVIEW.
1.
HAVE YOU REGULATED WORK PERFORMED BY THE APPLICANT? YES [ ]
NO [ ]
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2.
HAS THE WORK BEEN PERFORMED IN COMPLIANCE WITH STATE LAWS AND RULES? YES [ ]
NO [ ]
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3.
HAS THE APPLICANT BEEN CONVICTED OF A CRIME RELATING TO SEPTIC TANK CONTRACTING, OR HAS
ANY ENFORCEMENT ACTION BEEN TAKEN AGAINST THE APPLICANT? YES [ ]
NO [ ]
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
REVIEWED BY:_________________________________________________ TITLE ______________________________________
OFFICE _____________________________ TELEPHONE _____________________________ DATE ______________________
Application Check No.
FOR
Registration Check No. ____________
Date of Application Check:
HSES
Date of Registration Check _________
Check Amount:
OFFICE
Check Amount ___________________
Date of Approval/Denial:_______________
USE
Registration Number ______________
Approved By
_____________________
ONLY
Date Issued _____________________
Examination Date _____________________
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTOR REGISTRATION
ATTACHEMENT 1: SEPTIC TANK CONTRACTS
LIST THE 25 MOST RECENT CONTRACTS COMPLETED IMMEDIATELY PRECEDING THE DATE OF FILING.
JOB DESCRIPTION
LOCATION
CUSTOMER
PERMIT
DATE
SEPTIC TANK
NEW, REPAIR,
LOT / ADDRESS
OWNER
NUMBER
COMPLETED
CONTRACTOR
PUMPOUT
CITY, ST, ZIP
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
CONTINUED ON REVERSE
DH 4075A, 1/97 (Obsoletes Previous Editions) Incorporated: 64E-6.019, FAC
JOB DESCRIPTION
LOCATION
CUSTOMER
PERMIT
DATE
CONTRACTOR
NEW, REPAIR,
LOT / ADDRESS
OWNER
NUMBER
COMPLETED
PUMPOUT
CITY, ST, ZIP
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Page of 4