Official Use Only:
Application No._____________
Fee Paid $_______Date_______
Check #____________________
STATE OF FLORIDA
DEPARTMENT OF HEALTH
ENVIRONMENTAL ENGINEERING
APPLICATION FOR VARIANCE FROM CHAPTER 64E-9,
FLORIDA ADMINISTRATIVE CODE
SWIMMING POOLS AND BATHING PLACES

															
In order to solicit a variance recommendation from the Advisory Review Board, it is necessary to have a letter or inspection report from environmental engineering or the local county health department indicating that your proposed project, plan, or product does not meet one or more of the rule requirements set forth in Chapter 64E-9, Florida Administrative Code.  A copy of the letter or report must accompany this application.  Additionally, a processing fee of $300 must be provided.
PART I (To be completed by the applicant):
1. Name of Agent or Applicant: 												

2. Street Address: _______________________________________ City: 							

    State : _____________ Zip: ____________ Telephone: (     )	   -  		

3. Name of Plan, Project, or Product :											

    Street Address: _______________________________________ City: 							

    State : _____________ Zip: ____________ Telephone: (     )	   -  		County:					

4. Name of Contractor: 													

    Street Address: _______________________________________ City: 							

    State : _____________ Zip: ____________ Telephone: (     )	   -  		  License Number: __________

5. Engineer's Name and License #: 								

6. State reason(s) for variance request.  Attach eight copies of applications, drawings, specifications, photos, etc., that clearly illustrate this variance request.  (Attach separate sheet if necessary.) 

															

7. State hardship and justification as to why the variance would relieve the hardship. (Attach separate sheet if necessary.)

															

8. State any additional reason or provide any technical documentation to support your supposition that a variance would not likely result in an impairment to public health.  (Attach a separate sheet if necessary.) 

															

9. Forward to environmental engineering or local county health department having authority for review and  completion of Part II.

															
    Signature of Owner or *Owner's Agent							Date of Application

										*Provide a letter from owner granting 	DH 4080, 7/08,    64E-9.003, F.A.C.						  permission to act on his behalf.

PART II (To be completed by Environmental Engineering/County Health Department prior to submittal.):

1. Specific Section(s) of Chapter 514, F.S. and/or 64E-9, F.A.C. involved in this variance:

    															

    															

    															

2. State facts regarding this matter that would help make informed decisions.:

    															

    															

    															

															

    															

    															

3.
    The department is aware of this request and has collected the appropriate fee.

 															
    DOH Engineer/Environmental Health Director					Date

Instructions for CHD and/or Environmental Engineering:

1.	County Health Department shall forward completed application and fee to The Bureau of Water Programs in Tallahassee.

2.	In the spaces above list any additional details of your evaluation telling why the standards cannot be met and/or why they should be met.

3.	This completed form must be received in the above office at least 30 days in advance to any scheduled Advisory Review Board meeting date.

4.	Attach any supporting documentation you deem necessary to clearly explain the code violation and the variance request.