"Septic Tank Contractor Registration Packet" - Florida

This "Septic Tank Contractor Registration Packet" is a document issued by the Florida Department of Health specifically for Florida residents with its latest version released on July 1, 2017.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Florida Department of Health.

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Download "Septic Tank Contractor Registration Packet" - Florida

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FLORIDA DEPARTMENT OF HEALTH
BUREAU OF ENVIRONMENTAL HEALTH
SEPTIC TANK CONTRACTOR
REGISTRATION PACKET
THIS PACKET CONTAINS:
 APPLICATION PROCEDURES
 APPLICATION FOR SEPTIC TANK CONTRACTOR REGISTRATION
 PART III OF RULE 64E-6, FLORIDA ADMINISTRATIVE CODE
 PART III OF CHAPTER 489, FLORIDA STATUTES
 FREQUENTLY ASKED QUESTIONS
July, 2017
FLORIDA DEPARTMENT OF HEALTH
BUREAU OF ENVIRONMENTAL HEALTH
SEPTIC TANK CONTRACTOR
REGISTRATION PACKET
THIS PACKET CONTAINS:
 APPLICATION PROCEDURES
 APPLICATION FOR SEPTIC TANK CONTRACTOR REGISTRATION
 PART III OF RULE 64E-6, FLORIDA ADMINISTRATIVE CODE
 PART III OF CHAPTER 489, FLORIDA STATUTES
 FREQUENTLY ASKED QUESTIONS
July, 2017
SEPTIC TANK CONTRACTOR REGISTRATION PROCEDURES
APPLICATION
Two (2) signed statements from persons not related to the
applicant, for whom the applicant has provided services in the
The applicant must complete Sections I through III of the application.
onsite sewage industry, stating what services were provided.
Section IV must be completed by the local county health department
Certification from a registered septic tank contractor or
where the applicant intends to provide septic tank contracting
plumbing contractor of the applicant’s employment dates and
services, regardless of whether work by the applicant has been
work responsibilities.
regulated by that health department. The application must be mailed
Documentation of payment of federal withholding tax, and
by the applicant, with the required support documentation and
social security as required by law.
For principle corporate
application fee of $75.00 (check or money order), payable to the
Department of Health to:
officers, or partners in a partnership, legal documentation of
their position in the corporation or partnership may be
MAILING ADDRESS
substituted for withholding tax, social security, and worker’s
Department of Health
compensation documentation.
Bureau of Environmental Health
Application fee of $ 75.00.
4052 Bald Cypress Way, Bin # A08
Tallahassee, Florida 32399-1710
REGISTRATION EXAMINATION
PHYSICAL ADDRESS
The examination is open book. It consists of one-hundred (100)
questions based on Chapter 64E-6, Florida Administrative Code,
Department of Health
(FAC), sections 381-0065 - 381-00655 of Chapter 381 and Part III,
Bureau of Environmental Health
Chapter 489, FS. A minimum score of 75% is required. Applicants
4025 Esplanade Way, Room 130
who pass the examination must pay a $100.00 fee to complete
th
Tallahassee, Florida 32399-1710
registration. Registrations expire on September 30
following the
effective date of the certificate.
Contractors must complete a
Completed application and all required support documentation must
minimum of six classroom hours of approved training for renewal
be received by the department’s Bureau of Environmental Health at
each year.
least 21 days prior to examination.
This office reviews each
application to determine the applicant’s eligibility for examination.
AUTHORIZING A SEPTIC TANK BUSINESS
If eligible for examination, the applicant is notified of an
Most septic tank contracting services require a certificate of
examination date.
If the applicant is determined ineligible for
authorization. The structure of a business determines whether a
examination, the applicant is notified of the reasons for the
certificate of authorization is required. Septic tank contracting
determination. If determined ineligible, the applicant may petition
businesses which are sole proprietorships operating under the full
for a hearing under section 120.57, Florida Statutes, (FS), within 21
name of the owner are not required to obtain a certificate of
days of the denial notification.
authorization. An individual offering contracting services under a
fictitious name is required to obtain a certificate of authorization.
Businesses which are structured as partnerships, associations or
SUPPORT DOCUMENTATION
corporations are also required to obtain a certificate of authorization.
All contractors who act in behalf of the business as contractors and
Applications submitted without the following support documentation
one or more of the principal officers must be registered septic tank
are incomplete and may be returned to the applicant or denied.
contractors. The certificate of authorization is valid for a two-year
th
period, expiring on March 31
of odd years. The biennial
Out-of State Work Experience - If an applicant's experience
application fee for a certificate of authorization is $250.00. If
was obtained in another state, a letter from the regulatory
application is made within the second year of this period, a pro-rated
fee of $125.00 is required. Application for a certificate of
agency of that state must address the following questions and
authorization is made after completing registration requirements.
must accompany the application. A. Does the applicant hold a
statewide license for septic tank contracting? B. How long has
the applicant been a statewide licensed septic tank contractor?
C. In order to obtain the statewide septic tank license, was the
applicant required to take and pass an examination on the
following topics: system location and installation; site
evaluation criteria; system size determinations; disposal of
septage; construction standards for drainfield systems and U.S.
Department of Agriculture Soil Textural Classification? D. Are
continuing education courses required annually for license
renewals?
Attachment I completed in full.
Two (2) recent color passport style photographs, not older than
12 months and 1 1/2 X 1 1/2 inches in size.
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
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