The DOH 4082 form, issued by the State of Florida Department of Health, serves as an application for a permit concerning migrant labor camps or residential migrant housing. This comprehensive document is integral for operators who aim to establish or maintain facilities accommodating the specific needs of the migrant population in Florida. Covering a broad spectrum from communal living spaces in labor camps to individual residential units, the form requires detailed information about the operator, housing facilities, and the services provided, including sanitation, water supply, and waste disposal. The distinction between migrant labor camps, characterized by shared amenities, and residential migrant housing with individual facilities, underscores the form’s adaptability to different types of migrant accommodations. Additionally, the form mandates operators to pledge compliance with Chapter 64E-14, Florida Administrative Code, and other relevant regulations, ensuring that facilities meet health and safety standards. By providing sections for Department of Health officials' use, including permit summaries and recommendations, the form also facilitates a streamlined review and approval process, making it a critical step for operators in legitimizing their operations and contributing to the wellbeing of Florida's migrant workers.
| Question | Answer |
|---|---|
| Form Name | Doh Form 4082 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | MIGRANT, dormatories, Obsoletes, da form 4082 |
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR A MIGRANT LABOR CAMP
OR RESIDENTIAL MIGRANT HOUSING PERMIT
|
|
|
Authority |
|
|
|
Chapter |
|
|
|
Chapter |
Name of Operator: ______________________________________ |
______________________ |
_________ |
____________________ |
(Last) |
(First) |
|
(Telephone) |
Street Address: _____________________________________________ |
__________________________________ ___________ |
____________ |
|
|
City |
State |
Zip |
Mailing Address If Different: __________________________________ |
___________________________________ |
___________ |
____________ |
|
City |
State |
Zip |
Doing Business As: __________________________________________ |
___________________________________ |
__________ |
____________ |
Company Name |
City |
State |
Zip |
Name of Facility:
_________________________________________________________________________________________________________________________________
Location of Facility: _______________________________________________________________ |
_______________________________________ |
|
County |
Types of Housing Provided – Complete A, B or both based on the description of housing below |
|
A.Migrant Labor Camp
Note: Migrant labor camps have communal gang type toilet and shower facilities or a central mess hall or both and may be occupied by singles or families, but the preferred use is for singles.
1.) |
Number of dormatories |
|
[ |
|
] |
|
2.) |
Number of barracks |
|
[ |
|
] |
|
3.) |
Number of rooming houses |
|
[ |
|
] |
|
4.) |
Number of other building structures |
[ |
] |
|||
5.) |
Proposed number of residents |
|
|
|
|
|
|
to occupy all buildings |
[ |
] |
|
|
|
Facilities Provided (Migrant Labor Camps Only) |
|
|
|
|
|
|
1.) |
Number of communal toilets |
|
[ |
|
] |
|
2.) |
Number of communal urinals |
|
[ |
|
] |
|
3.) |
Number of communal showers |
|
[ |
|
] |
|
4.) |
Number of communal hand washing sinks |
[ |
|
] |
||
5.) |
Number of drinking fountains |
|
[ |
|
] |
|
6.) |
Number of mess halls |
|
[ |
] |
||
|
|
|
|
|
|
|
B.Residential Migrant Housing
Note: Residential migrant housing has its own toilet, hand washing, shower, cooking and refrigeration facilities within the living unit.
1.) Number of single family living units including mobile home units:[ |
] |
|||
Duplexes |
[ ] Triplexes [ ] |
Quadriplexes [ |
] |
|
Apartments[ ] Rooming Houses |
[ ] |
|
|
|
2.) |
Total number of |
] |
|
|
C.This Section Must be Completed for A or B Above
Type of Water Supply Provided: |
Type of Sewage Disposal: |
|
|||
Municipal |
[ |
] |
Municipal |
[ |
] |
Private Well |
[ |
] |
Septic Tank |
[ |
] |
Other |
[ |
] |
Package Treatment |
[ |
] |
|
|
|
Other |
[ |
] |
I agree to operate and maintain the facility described above in compliance with Chapter
________________________________________________ |
|
|
_____________________________________________________ |
|
|||||
|
Date of Application |
|
|
|
Signature of Operator/Owner |
|
|||
|
|
|
|
|
|
|
|||
See Instructions on back |
|
Below for Completion by DOH Officials |
|
|
|
|
|||
Permit Summary: |
|
|
|
Recommendation |
|
Action |
|
||
Date Application Received |
___________ |
[ |
] Approval |
|
[ |
] |
Approved |
|
|
Previous Permit Number |
___________ |
|
|
|
|
|
|
|
|
Date Permit Issued |
___________ |
[ |
] Disapproval |
|
[ |
] |
Disapproved |
|
|
Class of Water System |
____________ |
|
|
|
|
|
|
|
|
Water Supply Approval |
____________ |
|
|
|
|
|
|
|
|
Authorized Capacity |
____________ |
______________________________________ |
____________________________________ |
||||||
Sewage Disposal Approval |
____________ |
Authorized Signature, |
Date |
Authorized Signature, |
Date |
||||
Water System Upgrade |
____________ |
______________________________________ |
____________________________________ |
||||||
New Audit Control No. |
____________ |
|
Title |
|
|
|
Title |
|
|
DOH Form 4082, |
June 98 (Obsoletes previous editions which may not be used) |
|
|
|
|
|
|||
(Stock Number: |
|
|
|
|
|
|
|
||