STATE OF DELAWARE
DIVISION OF PUBLIC HEALTH

APPLICATION FOR CLASSIFICATION AS A PRIVATE POOL

Complete and return the original application form to Doug Lodge at the Office of Drinking Water 
(655 Bay Rd. Suite 203 Dover, DE 19901). Retain a copy for your records.  If you have any 
questions regarding this form, please contact the Office of Drinking Water (302) 741-8630.

Name of Facility	__________________________________________________________________________	  													

Mailing Address 	__________________________________________________________________________

		  	__________________________________________________________________________													
																	
Location (if different)	__________________________________________________________________________  													

Contact Person	_____________________________________________	Tel. # 	__________________________  				

Pursuant to Sections 26.105 & 26.126 of the “State of Delaware Regulations Governing Public 
Pools,” I/we the undersigned affirm that the above facility is in full compliance with all of 
the following criteria for classification as a private pool.  I/WE HAVE PROVIDED PROOF OF THIS 
COMPLIANCE, e.g., COVENANT, BY-LAWS, SALES AGREEMENT, and I/we agree to promptly notify the 
Division of Public Health if this facility is no longer in compliance with any of these criteria:

1.	The pool(s) is/are owned by a legal entity which is in turn owned by the beneficial 
        owners;
2.	Pool ownership is part of the ownership of real property by the beneficial owners;
3.	The beneficial owners are able to assert ultimate dominion and control over access to 
        and maintenance of the pool(s);
4.	No pool memberships are available to non-beneficial owners.

26.105	“Beneficial Owner” means an ownership interest in the entity owning the pool through 
        direct ownership of the real property where the pool is located, direct ownership 
        of stock in a stock corporation owning the real property where the stock represents 
        an equity interest in the corporation, or direct ownership through being a member in a 
        limited liability company (L.L.C.) or a partner in a partnership owning the real 
        property upon which the pool is placed.

________________________________________________	__________________________________________														
Name of Applicant (please print)			Name of Applicant (please print)

________________________________________________	__________________________________________															
Signature & Title of Applicant				Signature & Title of Applicant

_______________________					_______________________															
Date							Date

DO NOT WRITE BELOW THIS LINE – FOR HEALTH DEPARTMENT USE ONLY		
       
This application for classification as a private pool is	_____ APPROVED	_____ DISAPPROVED

If disapproved, specify reason(s)  											

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________
															

_________________________________________________	_______________________
Signature of Program Administrator 			Date 	

Doc # 35-05-20/08/02/42