APPLICATION FOR A PUBLIC POOL OPERATING PERMIT

This application must be completed for each new public pool, or an existing public pool if 
there is a change in name or ownership.  Return this application to the address below and 
please make a photocopy for your records.  AN APPLICATION MUST BE SUBMITTED FOR EACH POOL 
(i.e., a facility with a swimming pool (SwP), a wading pool (WP) and a spa pool (SpP) 
must submit three (3) applications).  INCOMPLETE APPLICATIONS MAY BE RETURNED.  If there 
are any questions regarding this form, call (302) 741-8630.  PLEASE PRINT OR TYPE.

Doug Lodge, Environmental Engineer IV
Blue Hen Corporate Center
655 Bay Road, Suite 203
Dover, DE  19901

Application is for:  a new pool _____; an existing pool (change of  name or ownership) _____

FACILITY/POOL NAME _________________________________________________________________________
													
MAILING ADDRESS	____________________________________________________________________________
		
		____________________________________________ PHONE # _______________________
						
LOCATION (if different) ____________________________________________________________________

			____________________________________________________________________													


PERSON IN CHARGE (*) (pool owner) _____________________________	PHONE #_____________________

APPROVED POOL OPERATOR (**) ___________________________________ PHONE #_____________________
				
TYPE OF POOL 
(choose only one): Swimming Pool-SwP _______   Wading Pool-WP _______   Spa Pool-SpP _______
  
          			Water Slide Flume-WSF _____  Special Purpose Pool-SpPP _____
       
VOLUME (gal) __________________	SOURCE OF POTABLE WATER ____________________________________
							
TYPE OF FILTRATION:      Sand _______   Diatomaceous earth-D.E. _______  Cartridge _________

TYPE OF DISINFECTION:  	Chlorine without stabilizer (cyanuric acid) 	______
			Chlorine with stabilizer  			______     	
			Bromine						______

This pool is: Indoors ______     Outdoors _____    Daily operating hours ___________________
								
This pool is: Open year around _____  Opens (date)______________ and closes ________________
 				
Name of Applicant _________________________________________  Title/Position_________________
						
Signature of Applicant ____________________________________   Date _________________________
					
(NOTE-IF YOU PLAN ANY CHANGES OR REHABILITATION WORK ON THIS POOL, PLEASE CONTACT DOUG LODGE, 
655 BAY ROAD SUITE 203 DOVER, DE 19901 - PHONE (302) 741-8630 TO DETERMINE IF PLANS AND 
SPECIFICATIONS MUST BE SUBMITTED FOR A CERTIFICATE OF APPROVAL.)

DO NOT WRITE BELOW THIS LINE - FOR REGULATORY AGENCY USE ONLY				

This public pool operating permit application is ____ APPROVED   ____ DISSAPPROVED   

[If disapproved, specify reason(s)]         

____________________________________________________________________________________________

____________________________________________________________________________________________

															
_______________________________________________	        ____________________________________    
(Signature of Program Manager)				(Date)


_______________________________________________		____________________________________														
(Signature of Program Administrator)			(Date)

(*)  See Section 26.121 of the Regulations		
(**) See Sections 26.102 and 26.205 of the Regulations

Doc. # 35-05-20/08/02/41