HomeMy WebLinkAboutDOH APPLICATION FOR POOL11
KANNED
BY
St. Lucie Count,
frsra
For Department Use Only
Fee Received $ Date
Check# From
Application Type: (check box, see instructions on back)
[ ] Initial Permit [XI Modification Operating Permit #
[ ] Transfer, change of owner or name
[ ] Renewal
REPLASTER, RETILE, RESET PAVERS
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR A SWIMMING POOL OPERATING PERMIT
This original form is to be completed and submitted with one copy, a set of construction plans & specs, a copy of the building
departments final inspection along with the appropriate fee.
1. Name of Project /Facility TREASURE COVE DUNES CONDO ASSOC County SAINT LUCIE
Address of Pool4100 N HWY AIA
FT PIERCE
KLGZi7
2. Name of Owner TREASURE COVE DUNES CONDO ArS$QF, Phone (30� 433-1870
Mailing Address 4100 N HWY AlA. City FT PIERCE State FL Zip 34949
3. Building Department Name: SLC BLDG DEPT JOB CICIO 7( 7i-462-6453
2300 VIRGINIA AVE FTVYAET FL34982 Phone Number
P.O. Box or Street Address City, State. Zip Code
cicioj@stlucieco.org
E-mail Address
4. Pool Water source ON SITE
5. Lighting (check one): (X) No Night Shimming
( ) Outdoor. Three foot candies overhead and 1/2 watt per square foot of pool surface area underwater
( ) Indoor. Ten foot candles overhead and 8/10 watt per square foot of pool surface area underwater
6. Pool Volume in Gallons: Main Pool ON FILE Wading Pool ON FILE Spa Pool ON FILE Other ON FILE
7. Pool Bathing Load: ON FILE Number of Dwelling Units ON FILE
ON �77 E pN FILE ON.'I ON FILE ON FILE
B. Poo! Dimensions: Width: -Le ngth:_iirea:_Perlmeter_ Oeb& Max._ Min._ Shape:
9. Water Treatment Equipment Make and Model:
(A) Recirculation Pump: Flow GPM At TDH HP,
(B) Filter.
(C) Disinfection Equipment
(Secondary Disinfection if)
(D) pH Adjustment Feeder:
(E) Test tit
10. Equipment Substitutions
Area sq. Ft Flow
Capacity (GPD)or(PPD)
Capacity
DH 4159, Eft. 10/2014 (Obsoletes DH9167108 and OH918 5/12 editions) 64E-9.001, F.A.C. Page 1
SEP 1 1 AEC'D
CERTIFICATION OF OWNER
The undersigned owner, or owner's representative, hereby agrees to operate the pool described in this application in accordance with
the requirements of Chapter 514 of the Florida Statutes (F.S.), and Chapter 64E-9 of the Florida Administrative Code, and maintain the ----
original construction approved under the Florida Building Code by the jurisdictional building department. This agreement includes
keeping a daily record of the information regarding pool operation on the monthly report form furnished by the department or on other
forms approved by the department and when requested, submission of the completed form to the appropriate county health
department.
its %J t -- Pfn of 0M iL4 R�wr7 f , l l J (w
Signed, �11� °- L
Name F6N rr- RUM _ Tit4as i F en l�
(print or type) (print or type)
REMARKS; POOL AND DECK RENOVATION NO STRUCTURAL POOL CHANGES. REPLASTER, NEW TILE
NEW PAVERS AND REWORK EXISTING, REPLACE EXISTING EQUIP- LIKE FOR LIKE CHANGE OUTS.
NO MODIFICATION NEEDED ON ANYTHING. BLDG DEPT HAS TOTAL SCOPE OF WORK.
Desion Engineer/Architect Name: Telephone:
Building Department Construction Approval Date Approval
CERTIFICATION OF INSPECTION
I hereby certify 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
I ] Change data entered into EHD by on
Instructions- Before submitting application to DOH:
For Initial Permit: Complete the entire application with owner certification. Include original and one copy of this
completed form, a copy of construction plans & specs submitted to the building department (electronic copy in PDF, TIF or
JPG format is acceptable), a copy of the building department final inspection approval, and the appropriate fee. Provide .
design engineers name and phone number in REMARKS. The operating permit number will be entered by DOH staff.
For Modification: Complete items 1 - 3, enter existing operating permit number, note proposed or completed changes in
the appropriate sections, and complete the owner certification on page 2. Include a copy of the construction plans &
specs submitted to the building department (electronic copy is acceptable) and a copy of the building department's final
inspection approval. Provide design engineer's name and phone number in REMARKS.
For Transfer: Complete items 1 and 2, enter existing operating permit number, then note changes in the page 2 owner
remarks section, and complete the owner certification on page 2. There is no fee or building plans required for a transfer
permit reissued due to Change of ownership, name of facility, phone number, or mailing address.
For Renewal: Complete items 1 and 2, enter existing operating permit number, and complete the owner certification on
page 2. There is an annual operating permit fee charged for renewal.
OH 4159, Eff. 10114 (Obsoletes DH9167/08 and DH918 5/12 editions) 64E-9.001, F.A.C. Page 2 of 2