HomeMy WebLinkAboutAPPLICATION FOR A SWIMMING POOLM E E I For Departent Use On
ee Received $ t Date 3 ! J
O.-MVP-11 SCANNED AUG 3 0 2018 he k# From
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Rq I OP�r°n�? �a�iY�(��
Application Type:J(check'bo , see Instructipl(t�sihEg*kucie County
RECB41] titial Perml l X Modification ENVIRONMENTAL HEALTH Operating Permit # e�ra -60- I00 t Z
[. ] Transfer, ch nge of owner or name 0001.3
AUG S[ O]newal
Permitting Department ISTATE OF FLORIDA
St. Lucie County
-DEPARTMENT OF HEALTH
PPLIGATION FOR A SWIMMING POOL OPERATING PERMIT
1. Project /Facili (Name: •� County: JT -
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Address of Po'I: 0 = ,1City: 1�� -Zip:
2. Owner Name: J �+ �� E-Mail: Phone: ( )
Mailing Addre Is: / /S �S� ii�='�%it�- �C�i�l State: zip:
3. Building Dept (Name:
Mailing Addresb City Zip
II (�
E-mail Address Phone Number
4. Design Engi eer/Architect Name:
Phone Num �er:" E-mail:
5. Pool Water Source (Name of Public Water System):
6. Lighting (ch Ilck one): - (. ) . No Night Swimming
( ) Outdoor:' Three foot candles overhead and 1/2 watt per square foot of pool surface area underwater
( ) Indoor: tTen foot candles overhead and 8/10 watt per square foot of pool surface area underwater
7. Pool Volum in Gallons: Main Pool Spa Pool Other
8. Pooh@athinll Load: Number & Type of Dwelling Units Served:
9. Pool Dime i ions: Width: Length: Area: Perimeter: Depth: Max. Min.
10. Water Treatment Equipment Manufacturer and Model:
(A) Rllcirculation Pump: Flow GI?M At TDH HP
(B) F Iter: Area: Sq. Ft. Flow Capacity GPM
(C) Isinfection Equipment: Capacity (GPD) or (PPD)
(Secondary Disinfection if Applicable):
(D) dIH Adjustment Feeder: Capacity. (GPD)
(E) est Kit: -
11. Other Eq lipment Details:
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DH 4159, 9ii 015, Rule 64E-9.001(3), F.A.C. 9
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REMARKS:
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CERTIFICATION OF OWNER
The undersi ned owner, or owner's representative, hereby agrees to operate the pool described in this application in accordance with
the require ents of Chapter 514 of the Florida Statutes (F.S.), and Chapter 54E-9 of the Florida. Administrative Code, and maintain the
original con truction appr6ved.under the Florida Building Code by the jurisdictional building department. This agreement includes
keeping'a d ily record of the information regarding pool operation on the monthly report form furnished by the department or on other
forms appro ed by the depart7nt and when requested, submission of the completed form to the appropriate county health
department
�
Sign: � 3v
I Date:
Pn:nt or typ ej me:Title:
(-{�yq ('
(Print or type) If not the Owner, attach aufhorization from Owner
THIS
FOR DOH USE ONLY:
Building D6bartment Construction Approval Date: Approval Number:.
CERTIFICATION OF INSPECTION—
i
I hereby c rtify that an inspection of this pool has been made and the foregoing information is correct to the best of my knowledge and
belief. It is recommended the first annual operating permit be granted subject to the provisions of the Florida Administrative Code.
Signature 'DOH Engineer/Authorized Staff
Print Name
ata entered into EHD b
[ ]Chan e d y
on
Date
Instructlgns- Before submitting application to DOH:
For Initial' Permit:. Complete the entire application with owner certification. Include the original and one copy of this completed form, a
copy of c nstruction plans & specs to be submitted to the building department (electronic copy in PDF, TIF or JPG format is
acceptab e), and the appropriate fee. The operating permit number will be entered by DOH staff. This application will not be complete
until a cc I y of the final building department inspection is received.
For Mod fication: Enter existing operating permit number, complete items 1 - 4, note proposed or completed changes in the
appropriate sections, and complete the owner certification. Include•a copy of the construction plans & specs to be submitted to the
building department (electronic copy is acceptable). This application will not be complete until a copy of the final building department
inspection is received.
For Tra sfer: Enter existing operating permit number, complete items 1 and 2, then note changes in the remarks section, and
complet the owner certification. There is no fee or building plans required for a transfer permit reissued due to change of ownership,
name ofl, acility, phone number, or mailing address....
For Renewal: Enter existing operating permit number, complete items 1 and 2, and complete the owner certification. There is an
annual operating permit fee charged far repewal.
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DH 41511, 9/2015, Rule 64E-9.001(3), F.&C. Page 2 of 2