HomeMy WebLinkAboutAPPLICATION FOR A SWIMMING POOL PERMITSCANNED
BY
St. Lucie County
Application Type: (check box, see instructions onback)
[ ] Initial Permit [ ] Modification
[ ] Transfer, change of owner or name
[ ] Renewal
Department Use Only
Fee Received $ Date
Check# From
Operating Permit;- 5460- d�oZ d-3
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR A SWIMMING POOL OPERATING PERMIT
Se awaa-b 4-r �f'ad l�t C- V i QL�i County:
1. Project /Facility Nameg � f /� /J (�
Address of Pool: - 0 S C e V t w/ City f�r'e/i C Zp: y
+/3 L/
i 'JA t.Jo6Q 4 AT- /4- 1 of m 4-i L 9r5oe. �
2. Owner Name: V i P 4 % �J� +E-MaiI:I�A/�tz i SP <<�'vsii�ty+A kone
Mailing Address: !!c �i o� L City �Q2a Prit_!rs[ate: �-C—Zp: e G
3. Building Dept Name: `J ki,2c i '--e
"n ' P'-49
D-77ObJ U+6LC�irJf4 a/ -I`>-' �( e,�+2C'Q p
Mailing Address City
4. Design Engineer/Architect Name:
Phone Number. E-mail:
r � t /
5. Pool Water Source (Name of
1fof. Public Water System): f PI Q/t C�
6. Lighting (check one): (2Q No NightSwimming
( ) 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
7. Pool Volume in Gallons: Main Pool-! 41 l Spa Pool Other
8. Pool Bathing Load: 3 0 Number & Type of Dwelling Units Served:
9. Pool Dimensions: Width: �0 LengOr.— Area: l fl Perimeter. Depth: Max
4Min. +
10. Water Treatment Equipment `&a idTecturer and Model:
GPM A(_TDH HP
(A) Recirculation Pump: Flow
(B) Filter. D r , S < y �i 'c + Area: Sq. Ft Flow Capacity 7 S GPM
p k� r Capacity (GPD r (PPD)
(C) Disinfection Equipment ?�n)
(Secondary Disinfection if Applicable):
(D) pH Adjustment Feeder. Capacity (GPD)
(E) Test IGt
11.Other Equipment Details:
DH 4159. 912015, Rule 64E-9.001(3), F.A.C.
Page 1 of 2
s 1.: AI
N
1, P_ - 5 U rti' iF �-•,1 -a
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 hee county enttor on other
fortes approved by the department and when re led, submission of the completed form to the appropriate
department r3
/ Date: 3
f31gm: �
Cmv� Tina:
Name (Print or type) ti not the Owner, attach a r¢aeon from Owner
(Print or type)
THIS SECTION FOR DOH USE ONLY:
Building Department Construction Approval Date:
Approval Number.
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.
Date
Signature DOH Engineer/Authorized Staff
Print Name
( ] Change data entered into EHD by
Instructions- Before submitting application to DON:
For Initial Permit: Complete the entire application with owner certification. Include the original and one copy of this completed forth, a
lectronic copy
copy of construction plans & specs to be submitted to the building department (e. This application will not be complete
oPDF, TIF or JPG format is
acceptable), and the appropriate fee. The operating permit number will be entered by DOH staff.
until a copy f the final building department Inspection is received.
For Modification: Enter existing operating permit number, complete items 1 - 4, note proposed or completed changes n plans & specs to be submitted to the
In the
appropriate sections, and complete the owner certification. Include a copy of the constructio
building department (electronic copy is acceptable). This application will not be complete until a copy of the final building department
inspection is received.
For Transfer. Enter existing operating permit number, complete items 1 and 2, then note changes in the remarks section, and
complete the owner certification. 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: Ester existing operating permit number, complete items 1 and 2, and complete the owner certification. There is an
annual operating permit fee charged for renewal.
Page 2 of 2
DH 4159, 912015, Rule 64E-9.001(3), F.A.C. '