Allen County Pool & Spa Application License Application

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Allen County Pool & Spa Application License Application Powered By Docstoc
					                                            Fort Wayne-Allen County Department of Health
                                                      200 E. Berry St. Suite 360
                                                        Fort Wayne, IN 46802
                                                       Division of Pollution Control
                                                  (260) 449-7561 –fax (260) 449-3010
                                                  Annual Application for a Swimming
                                                           Pool/Spa Permit
                                                              (Please print)

       Name of Establishment (please print)                                     Address/Zip                              Address of Pool


       Renewal Letter Mailing Address (please print)                            Address/Zip                              Telephone #


       Permit Mailing Address (please print)                                    Address/Zip


       Contact Name / Pool Operator (please print)                                                                       Telephone #

                                                 Please Answer The Following Questions:

       1. Opening and Closing : Dates:_____________ Days:______________ Hours:____________________________
       2. Will the pool have food service? ………………………………Yes No (circle one)
       3. Applicant is a: ………………………………….Individual/Enterprise/Partnership/Corporation (circle one)
       4. Pool type as enumerated in 10-5-1-16………………..A B C D (circle one)
       5. Is the pool operated by a tax supported unit of the government?   Yes No (circle one)
        6. Pool water surface area (square feet) 1.___________2. ____________3._____________ 4.____________
        7. Pool water volume capacity (gallons) 1.___________2. ____________ 3._____________4.____________

       Allen County Code, Title 10, Article 5, Chapter 2, Section 2, stipulates that “It shall be unlawful for any person to operate
               a swimming pool in Allen County, Indiana, who does not possess a valid permit from the Health Officer.”

                                   Permit Fee Schedule

Permit Type                                                       Annual Fee                      Late Fee
                                                                                                                    # of Pools/ Spas: ________
                                                                                                                    (Annual)
Annual Pool/ Spa                                                      $400.00                     $500.00
Each additional Pool/ Spa at same address                             $ 80.00                     $100.00

Seasonal Pool/ Spa                                                    $200.00                                       # of Pools/ Spas: ________
(May, June, July, August or September)                                                                              (Seasonal)

Each additional Pool/ Spa at same address                             $ 80.00
                                                                                                                    Late Fees:     _________

Each tax supported unit of government                                 $ 80.00                     $100.00           Total Amount: _________



       Make all checks or money orders payable to: Fort Wayne-Allen County Department of Health (mail to address listed above)

       Signature of applicant(s) or corporate officer: ______________________________________________________________________________


                                                   Applicant: (do not write below this line)

       Examined and approved                                                                        District Number _______________
       Date: ______________                                                                         Establishment Number: _________
       Environmental Health Officer: ____________________                                           Date Received: ________________
                                                                                                    Amount Received: _____________
                                                                                                    Receipt Number: ______________
                                                                                                    Clerk: _______________________

				
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posted:5/23/2012
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