Pool Land Use Application - East Manchester Township
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31/29/15 rev.
East Manchester Township
Tax Map #_____ Parcel #_____
POOL LAND USE APPLICATION
Application Date:
_________________________
Applicant Name: _________________________________________________Telephone #: ________________
Address: ___________________________________________________________________________________
PROPERTY OWNER INFORMATION - (if different than applicant)
Name(s): ______________________________________________________Telephone #: __________________
Address: ___________________________________________________________________________________
PROPERTY INFORMATION
Address Work is Occurring At: _________________________________________________________________
Special Exception/Variance Granted: No Yes
_____________________________________________
(describe)
Lot Size: ________ Corner Lot? ________ Flood Zone? ________
(if yes, submit details including engineer's drawing)
Right-Of-Ways or Easements? ________ Is your property: Residential: ________ Non-Residential: ________
TOTAL EXISTING IMPERVIOUS SURFACE
Primary Structure:
________sq/ft
Existing Patio(s): ________sq/ft
Garage(s):
________sq/ft
Other:
________sq/ft
Existing Shed(s):
________sq/ft
Other:
________sq/ft
Existing Driveway(s): ________sq/ft
Other:
________sq/ft
Existing Deck(s):
________sq/ft
TOTAL:
_____________SQ/FT
Project Value: $__________________
IMPROVEMENT INFORMATION
Type of Pool: ________________________________________________________________________________
Height of Pool: ________ft
(over 24” needs a permit, between 24” and 46” you need a fence that is self closing and self
latching, over 46” you do not need a fence, but you need a lockable/removable ladder)
Foot print of Pool: ________sq/ft
Please make sure you provide information about the pump and electrical hook up with the distance of how
far apart the two are. Also, please provide the bird eye view drawing on the next page, with dimensions.
(if the owner or applicant is the contractor, just write “self”)
CONTRACTOR/BUILDER INFORMATION
Name: _____________________________________________________________________________________
Address: _______________________________________________________Telephone #: ________________
Person in charge of work: _________________________________________Telephone #: ________________
Note: An updated Certificate of Insurance must be on file with East Manchester Twp.
Workers Compensation Company and Policy#: __________________________________ Expiration: ______
Liability Company and Policy#: _______________________________________________ Expiration: ______
Agent: ________________________________________________
Phone Number: _____________________
Address: ___________________________________________________________________________________
717-846-2004
Inspection Agency:
Commonwealth Code Inspection Service, Inc.
The applicant hereby makes request for a permit under all applicable Codes of the Township of East Manchester and hereby
certifies, under the penalties of perjury, that all facts set forth above are true and correct and the actual work will be performed in
accordance with the above. All applicable construction must meet Code as defined within Act 45 - PA Construction Code
____________________________________________
Owner or Owner Agent's Signature
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