COUNTY OF SONOMA DEPARTMENT OF HEALTH SERVICES
ENVIRONMENTAL HEALTH & SAFETY
th
Street Santa Rosa, CA 95404
625 5
Phone (707) 565-6565 FAX (707) 565-6525
PUBLIC POOL PERMIT APPLICATION
Please answer all questions completely. Sign and date below. Retain last copy. Submit original to
APPLICANT:
the Environmental Health & Safety Section. Please print or type.
Pool name_________________________________________________________________________________________
Pool address_______________________________________________________________________________________
Pool owner_______________________________________________________ Phone __________________________
Operator/management company _______________________________________________________________________
Contact person________________________________________________ Phone __________________________
Mailing address (if different from above)
Street address__________________________________________________________________________________
City/zip________________________________________________________________________________________
On-site manager name______________________________________________ Phone __________________________
Pool service (if applicable)___________________________________________
Phone __________________________
Date pool will open ______________________________________ Permit fee due $______________________________
Additional Plan Check Hours _______ hrs. @ $_________ per hour Total Plan check fee due $ ___________________
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PERMITS ARE VALID MAY 1 THROUGH APRIL 30
. FEES WILL BE PRORATED ACCORINGLY.
I (we) understand that the permit, when issued in compliance with the applicable County Code, is
valid for the dates as specified on the permit and is not transferable upon change of ownership.
Permits may be suspended or revoked for good cause. I (we) agree to operate in compliance with all
applicable State health laws and the rules and regulations set forth by the State Department of Health
Services or the County Public Health Officer.
PLEASE MAIL PAYMENT WITH THIS APPLICATION
Name (print) _______________________________________________________________________________________
Signature(s) _______________________________________________________ Date ___________________________
Original application
Change of ownership
Renewal
For Office Use Only
For office use only:
Pool(s) _____ Spa(s) _____ PR # ________________________ District ______ Issue Permit ________ Approved by ____________
Cash
Check
Credit Card Trans # ________________ Date rec’d _______________________ By __________________
Total amount rec’d $________________________________
Print Form
Clear Form
pool permit.doc
Original–EH
Yellow–Owner
(Rev. Feb 2013)
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