STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR A SWIMMING POOL EXEMPTION STATUS 
MORE THAN 32 UNITS

This form is to be completed and submitted in duplicate, along with supporting documentation as necessary to the appropriate health department

1.	Name of Pool      	

	Location of Pool      	

	Permit number     	Date of issuance     	

2.	Name of Owner      	 Phone Number (   )     	

	Mailing Address      	 City      	 State   	 Zip      	

3.	THIS POOL MEETS THE FOLLOWING CONDITIONS FOR EXEMPTION QUALIFICATION:

	A. The condominium or cooperative association’s recorded documents prohibit the 	 Yes	 No
		rental or sublease of units for periods of less than sixty (60) days.
		( Attach supporting documentation, identification and description of units)

	B. The pool safety equipment will be maintained such that the life ring(s) with 	 Yes	 No
		rope attached and the shepherd hook(s) attached to a 16 foot one piece pole are
		mounted in a conspicuous place and are readily available for use.

	C. The water quality of the pool will be maintained as follows:	 Yes	 No
		(1) The pool water has at least 1.0 mg/L free active chlorine residual
			or 1.5 mg/L bromine residual.
		(2) Spa pool water shall have not less than 2 mg/L free active chlorine residual,
			or  3 mg/L bromine residual.
		(3) The pH range of the water shall be maintained between 7.2 and 7.8.
		(4) The water clarity shall be such as to be able to clearly see the main drain from the pool deck. 

CERTIFICATION OF OWNER

The undersigned owner, or owner’s representative, certify that this pool qualifies for exemption from supervision under Chapter 514, Florida Statute, and Chapter 64E-9 Florida Administrative Code, except for water quality and life saving equipment conditions listed above.  Additionally the owner or owner’s representative understands  that an annual inspection fee as established in Chapter 514 Florida Statutes and Chapter 64E-9 Florida administrative code must be paid to the appropriate county health department to cover the cost of an annual inspection.  If the exemption conditions change to eliminate the exemption status, this pool will be modified as necessary to comply with the provisions of the Chapter 64E-9 of the Florida Administrative Code. 
It will be the owner’s responsibility to inform any future owners of the conditions for this exemption status.

	Signature 	 Date 05/20/98

	Name/Title     	
		Please print or type

	

It is recommended that exemption status be  granted   denied, subject to the provisions of the Florida Administrative Code

		
	DOH Engineer / Environmental Specialist

	     	
	Print Name