Dh 4159 Form – Fill Out and Use This PDF

		For Department Use Only
		Fee Received $_________ Date ___________
		Check#_________ From _________________
		________________________________________
		_____________________________________
Application Type: (check box, see instructions on back)
[ ] Initial Permit	[ ] Modification	Operating Permit #	-60-

[] Transfer, change of owner or name

[] Renewal

STATE OF FLORIDA

DEPARTMENT OF HEALTH

APPLICATION FOR A SWIMMING POOL OPERATING PERMIT

1.

Project /Facility Name: _______________________________________________________________ County: ________________

Address of Pool:

City:

Zip:

2.

Owner Name:

E-Mail:_________________________ Phone: (__) _________

Mailing Address:

City: _

State: _______ Zip: _

3.

Building Dept. Name: ___________________________________________________________

_________________________________________________________

______________________________________________

Mailing Address

City

Zip

_______________________________

(___)___________________

E-mail Address

Phone Number

4.

Design Engineer/Architect Name: ______________________________________________________________________________

Phone Number: _______________________

E-mail: _______________________________________________

5.

Pool Water Source (Name of Public Water System):

6.

Lighting (check one): (

)

No Night Swimming

(

)

Outdoor:

Three foot candles 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_______________ Spa Pool_____________ Other

8.

Pool Bathing Load: ________________

Number & Type of Dwelling Units Served:

9.

Pool Dimensions: Width:

Length:

Area:

Perimeter:

Depth: Max._____ Min.______

10. Water Treatment Equipment Manufacturer and Model:

(A) Recirculation Pump: ___________________________________ Flow___________ GPM At___ ____TDH HP

(B) Filter:			Area:		Sq. Ft. Flow Capacity				GPM
(C) Disinfection Equipment:						Capacity			(GPD) or (PPD)

(Secondary Disinfection if Applicable):______________________________________________________________________

(D) pH Adjustment Feeder:

Capacity

(GPD)

(E)Test Kit:

11.Other Equipment Details:

DH 4159, 9/2015, Rule 64E-9.001(3), F.A.C.

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REMARKS:

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.

Sign:			Date:
Name:			Title:
(Print or type)			(Print or type) If not the Owner, attach authorization from Owner

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.

Signature DOH Engineer/Authorized Staff

Date

Print Name

[] Change data entered into EHD by ________________________ on __________________

Instructions- 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 construction plans & specs to be submitted to the building department (electronic copy in PDF, TIF or JPG format is acceptable), and the appropriate fee. The operating permit number will be entered by DOH staff. This application will not be complete until a copy of the final building department inspection is received.

For Modification: 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 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: Enter existing operating permit number, complete items 1 and 2, and complete the owner certification. There is an annual operating permit fee charged for renewal.

DH 4159, 9/2015, Rule 64E-9.001(3), F.A.C.

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