STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR ANNUAL RENEWAL OR REISSUANCE OF PUBLIC SWIMMING POOL/BATHING PLACE OPERATING PERMIT

This form is to be completed and submitted with plans and specifications in quadruplicate, along with the appropriate fee.

1.	Name of Facility      	

	Location of Facility      	 

2.	Name of Owner      	 Phone Number (   )     		

	Mailing Address      	 City      	 State   	 Zip      	

3.	Type of facility for which permit is requested:	 Conventional public pool	 Spa Pool
	 Wading Pool 	  Special Purpose Pool	 Water recreation Attraction
	 Other     	

4.	If it has been permitted in the past please provide:  Permit Number      	 Date of Permit      	

5.	Provide the Size of the Pool in Gallons      	Gallons

6.	Reason for this application:	 Annual renewal  	 Reissuance due to:

	 Name Change	 Ownership Change 	 Other      	

List any other changes that should be entered on the permit      	
     	
     	
     	
     	
NOTE:	Annual operating permits expire on June 30 each year.  Please submit this application with the appropriate fee to the county health department by June 1 to allow time for evaluation and processing prior to the expiration date.  Application for permit reissuance must be completed at the time of an event that requires changes in the permit.  A fee for reissuance of permit is not authorized.

	 Approved	 Disapproved

Signature of Health Official 	Date 05/28/98	

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