STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR A SWIMMING POOL EXEMPTION STATUS 
32 UNITS OR LESS

This form is to be completed and submitted in duplicate, along with supporting documentation as necessary.

1.	Name of Pool      	

	Location of Pool      	 

2.	Name of Owner      	 Phone Number (   )     	

	Mailing Address      	 City      	 State   	 Zip      	

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

	A. This pool will serve no more than 32 condominiums or cooperative living units.	 Yes	 No
		( Attach supporting documentation, identification and description of units)

	B. Condominium or living units being served by this pool are not licensed as a 	 Yes	 No
		public lodging establishment.

	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 conditions listed above.  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 	 Date05/19/98 	

	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