Dh 4015 Form – Fill Out and Use This PDF

The DH 4015 form is an official document issued by the State of Florida, specifically designed for the evaluation of existing onsite sewage treatment and disposal systems, including system repairs. It is intended to be completed by Florida registered engineers, department employees, septic tank contractors, or other certified individuals, requiring detailed information about the onsite sewage system's tanks and drainfield. This comprehensive assessment ensures that the septic systems are free from defects or leaks, have the correct tank volumes, and that the drainfields are sized and functioning properly. For those looking to conduct or update their sewage system evaluations, clicking the button below is the first step towards completing the DH 4015 form.

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Dh 4015 Form PDF Details

The DH 4015 form, utilized within the State of Florida, serves as a crucial document for the evaluation of existing onsite sewage treatment and disposal systems, as well as system repairs. It is a comprehensive form that requires completion by a Florida registered engineer, department employee, septic tank contractor, or another certified individual, ensuring all submitted documents are signed and sealed. The form covers a wide array of information, including existing tank details like size, material, and whether the tank is baffled, along with certification that the tanks have been pumped, are free of defects or leaks, and have the necessary solids deflection or outlet filter device installed. Also, it delves into existing drain field information, detailing the size, type, and configuration of the primary drain field system. Additionally, it includes failure and repair information, requiring input on system installation dates, type of waste, estimated sewage flow, site conditions, nature of failure, failure symptoms, and remarks for any additional criteria that may impact system design. The DH 4015 form stands as a vital tool in ensuring the effective management and oversight of onsite sewage treatment and disposal systems within the regulatory framework of the Florida Department of Health, emphasizing the state's commitment to public health and environmental protection.

Question	Answer
Form Name	Dh 4015 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	florida dh 4015, dh 4015, applicable septic certified get, form dh4015

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STATE OF FLORIDA	PERMIT #
DEPARTMENT OF HEALTH
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
ONSITE SEWAGE TREATMENT AND DISPOSAL SYSTEM
EXISTING SYSTEM AND SYSTEM REPAIR EVALUATION

APPLICANT: CONTRACTOR / AGENT:

LOT:BLOCK:SUBDIV:ID#:

================================================================================================

TO BE COMPLETED BY FLORIDA REGISTERED ENGINEER, DEPARTMENT EMPLOYEE, SEPTIC TANK CONTRACTOR OR OTHER CERTIFIED PERSON. SIGN AND SEAL ALL SUBMITTED DOCUMENTS. COMPLETE ALL APPLICABLE ITEMS. COMPLETE TANK CERTIFICATION BELOW OR NOTE IN REMARKS WHY THE TANKS CANNOT BE CERTIFIED.

================================================================================================

EXISTING TANK INFORMATION

[

] GALLONS SEPTIC TANK/GPD ATU

LEGEND:

MATERIAL:

BAFFLED:[Y / N]

[

] GALLONS SEPTIC TANK/GPD ATU

LEGEND:

MATERIAL:

BAFFLED:[Y / N]

[

] GALLONS GREASE INTERCEPTOR

LEGEND:

MATERIAL:

[

] GALLONS DOSING TANK

LEGEND:

MATERIAL:

# PUMPS:[

]

================================================================================================

I CERTIFY THAT THE LISTED TANKS WERE PUMPED ON

, HAVE

THE VOLUMES SPECIFIED AS DETERMINED BY [ DIMENSIONS / FILLING / LEGEND ], ARE FREE OF OBSERVABLE

DEFECTS OR LEAKS, AND HAVE A [ SOLIDS DEFLECTION DEVICE / OUTLET FILTER DEVICE ] INSTALLED.

SIGNATURE OF LICENSED CONTRACTOR

BUSINESS NAME

DATE

================================================================================================

EXISTING DRAINFIELD INFORMATION

[

] SQUARE FEET PRIMARY DRAINFIELD SYSTEM

NO. OF TRENCHES [

]

DIMENSIONS:

[

] SQUARE FEET

SYSTEM

NO. OF TRENCHES [

]

DIMENSIONS:

TYPE OF SYSTEM: [

]

[

] MOUND [ ]

STANDARD

[

] FILLED

CONFIGURATION:

[

] TRENCH

[

] BED

[

]

DESIGN:

[

] HEADER

[

] D-BOX

[

]

GRAVITY SYSTEM

[

] DOSED SYSTEM

ELEVATION OF BOTTOM OF DRAINFIELD IN RELATION TO EXISTING GRADE

INCHES [ ABOVE / BELOW]

SYSTEM FAILURE AND REPAIR INFORMATION

[

] SYSTEM INSTALLATION DATE

TYPE OF WASTE [

] DOMESTIC [

] COMMERCIAL

[

] GPD ESTIMATED SEWAGE FLOW BASED ON

[

] METERED WATER

[

] TABLE 1, 64E-6, FAC

SITE

[

] DRAINAGE STRUCTURES

[

] POOL

[

] PATIO / DECK

[

] PARKING

CONDITIONS: [

] SLOPING PROPERTY

[

]

NATURE OF

[

] HYDRAULIC OVERLOAD

[

] SOILS

[

] MAINTENANCE

[

] SYSTEM DAMAGE

FAILURE:

[

] DRAINAGE / RUN OFF

[

] ROOTS

[

] WATER TABLE

[

]

FAILURE

[

] SEWAGE ON GROUND

[

] TANK

[

] D BOX/HEADER

[

] DRAINFIELD

SYMPTOM:

[

] PLUMBING BACKUP

[

]

REMARKS/ADDITIONAL CRITERIA

SUBMITTED BY:		TITLE/LICENSE		DATE:
DH 4015, 08/09		which may not
DH 4015, 08/09	(Obsoletes previous editions	which may not	be used)	Page 4 of 4
Incorporated 64E-6.001, FAC				Page 4 of 4

INSTRUCTIONS:
PERMIT #	Permit tracking number assigned by department
APPLICANT	Property owner’s full name
CONTRACTOR/AGENT	Licensed contractor or property owner’s legal agent
LOT,BLOCK,SUBDIVISION	Legal description for property
ID #	Property appraiser identification number for property
EXISTING TANK
TANK 1	Complete tank size in gallons or gpd and mark appropriately.
	Complete LEGEND (SHO approval number), MATERIAL (concrete, fiberglass,
	polyethylene) and whether or not tank in BAFFLED.
TANK 2	Same as TANK 1.
GREASE INTERCEPTOR	Same as TANK 1.
DOSING TANK	Same as TANK 1. Complete # PUMPS installed.
TANK CERTIFICATION	Completed by registered septic tank contractor, state-licensed plumber, certified EH
	professional, or master septic tank contractor. Show the date the tanks were pumped, the
	name of the pumping company, how the tank volumes were determined (measurement of
	tank dimensions and calculation of volume, filling the tank from a metered water source,
	or recording the tank legend for known tanks). If tank dimensions are used, list the tank
	dimensions in the remarks section. Indicate whether the tank has a solids deflection
	device or an outletlet filter. If the tanks cannot be certified, note that fact in the remarks
	section.
EXISTING DRAINFIELD
FIELD 1	Complete size of drainfield in square feet, NO. OF TRENCHES (if applicable) and
	DIMENSION (bed width and length or trench width and total length of trenches).
FIELD 2	Same as FIELD 1
TYPE OF SYSTEM	Mark appropriate block
CONFIGURATION	Mark appropriate block
DESIGN	Mark appropriate blocks
ELEVATION	Record elevation of lowest point of bottom of drainfield in reference to natural grade
FAILURE / REPAIR INFORMATION
INSTALLATION DATE	Record year of original system installation
TYPE OF WASTE	Mark appropriate block
GPD	Provide estimated sewage flow to system based on metered water flow data (if available)
	or Table 1, whichever is greater.
SITE CONDITIONS	Mark all applicable blocks. Record any other significant conditions.
NATURE OF FAILURE	Mark all applicable blocks.
FAILURE SYMPTOM	Mark all applicable blocks.
REMARKS	Record any other significant criteria that may impact system design. If dimensions are
	used to determine tank volumes, list the tank dimensions in the remarks section. If the
	tanks cannot be certified as free of observable defects or leaks, explain in remarks.
SUBMITTED BY	Signature of person performing evaluation
TITLE/LICENSE	Title of department person or license number of other evaluators.
DATE	Date of evaluation.

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Dh 4015 Form – Fill Out and Use This PDF

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