DeKalb County Pool-Spa Permit Application by PermitDocsPrivate

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									                                                                                                           Division of Environmental Health
                                          Swimming Pool/Spa                                                        445 Winn Way, Suite 320
                                                                                                                         Decatur, GA 30030
                                        Permit Application Form                                                              (404) 508-7900
                                                                                                                      www.dekalbhealth.net

    This form must be completed for all new facilities and for any changes to facility information (Type or Print in Block Letters)

Facility Information (as it will show on permit)                                                         Phone:
Name:                                                                                                    Fax:
Facility Address:                                                                                        E-mail:
City:                                                                    GA Zip Code:                    Web site:

Facility Type:   Pool (Regular)               Wading/Kiddie Pool        Spray Pool              Whirlpool Spa
                 Waterslides/Splash Pool      Zero-Depth Entry Pool     Beach                   Indoor/Outdoor Pool
                 Special Purposes Pool        Wave Pool                 Watercourse Pool        Other
Seasonal Status:       Seasonal Pool        Year-Round Pool
Location:              Indoor       Outdoor      Indoor/Outdoor
Location Type:
       Apartment Complex        Condominiums       Subdivision    Hotel     School      Parks & Recreation     Other

       Owner Information (          if same as facility address)                 Billing Information (            if same as facility address)

                                                                               Management Company
Name:                                                                     Billing Name:
Address:                                                                  Bill to Attention:
City:                                                                     Address:
State:                Zip Code:                                           City:
Phone:                                                                    State:                 Zip Code:
                                                                          Phone:                Fax:
                                                                          Email:

Pool Contact Information
   On-site Contact (Condo & Homeowner Associations)                 Pool Service Company       Other
Contact Name:                                                                               Gate Code (for inspections):
Organization Name:                                                                                      Phone:
Address:                                                                                                E-mail:
City:                                             State:                   Zip Code:                    Web site:
Any Additional Information:

Certified Operator for Pool
Certified Operator Name:
Address:                                                                                        Phone:
City:                                            State:            Zip Code:                    E-mail:
Certified by:      DeKalb County Board of Health                   Fulton County Department of Health and Wellness
                   National Swimming Pool Foundation               The Association of Pool and Spa Professionals
                   Other
Certification Number:                             Activation Date:                       Expiration Date:

Is this a NEW application or a CHANGE to facility information?             New         Change – Effective Date

Applicant’s Signature                                                                      Date of Application:
Applicant’s Name Printed:                                                                  Title:



                                                             For Office Use Only
DHD Permit #                                           Permit Fee Paid                                 Date Paid
Change of Ownership                                    Name Change Fee Paid                            Date Paid

  DHD Information Entered       Folder Created          Folder Information Updated       Inspection     Payment Processed              Permit Issued

								
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