Dh 4015 Form PDF Details

The Department of Health (DOH) has released a new form, the Dh 4015, to be used for reporting long-term care services. The form is designed to assist in the collection and tracking of data on long-term care services provided in Rhode Island. The new Dh 4015 form must be used by all providers of long-term care services starting July 1, 2018. More information on the new Dh 4015 form can be found on the DOH website. Questions about the new form can also be directed to the DH Long Term Care Unit at 401-222-4373.

QuestionAnswer
Form NameDh 4015 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesflorida dh 4015, dh 4015, applicable septic certified get, form dh4015

Form Preview Example

STATE OF FLORIDA

PERMIT #

DEPARTMENT OF HEALTH

 

 

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

 

/

 

 

BY

 

 

 

 

 

 

 

 

 

, 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:

 

X

 

[

] SQUARE FEET

 

 

 

 

 

 

 

SYSTEM

NO. OF TRENCHES [

]

DIMENSIONS:

 

X

 

 

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

 

 

 

(Obsoletes previous editions

be used)

Page 4 of 4

Incorporated 64E-6.001, FAC

 

 

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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