Aquatic Facility Worksheet - Cheyenne Laramie County Public Health

Fee:(Required)

New Pool or Other Aquatic Facility: $380

New Spa: $250

Remodel: $125

Establishment Name:(Required)

Establishment Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Fax Number:

Contact Name:(Required)

First Last

Email:(Required)

Owner Name:(Required)

First Last

Owner Address:(Required)

Street Address Address Line 2 City State ZIP Code

Owner Phone:(Required)

Owner Email:(Required)

Enter Email Confirm Email

The following MUST accompany this application:

(Incomplete plans will not be accepted.)

One complete set of hard copy plans showing the layout, equipment room, bath house, and showing the side view of the aquatic facility.(Required)

Max. file size: 50 MB.

Specification (cut) sheets on the following equipment: Pump, filter, heater, disinfecting device, chemical feeders, flow meter, skimmers, water features, slides, and other important equipment. All equipment shall be NSF approved.

Drop files here or

Max. file size: 50 MB.

Certified Pool Operator Certificate for this aquatic facility.

Max. file size: 50 MB.

Is this Aquatic Facility: (check all applicable boxes)(Required)

General Use – open to any person who wishes to use it.

Limited Use – use limited to residents, members etc.

Annual

Temporary

Indoor

Outdoor

Night Swimming?(Required)

Yes

Water Source:(Required)

Wastewater Disposal:(Required)

Backflow Prevention Method:(Required)

Surface Area (sq.ft.):(Required)

Volume (gallons):(Required)

Length (feet):(Required)

Width:(Required)

Depth - Shallow End:(Required)

Depth - Deep End:(Required)

Filtration Rate (gpm):(Required)

Turnover Rate (min. / hr.):(Required)

Aquatic Facility Structure:

Poured Concrete

Gunite

Fiberglass

Other

Other:

Deck Finish Type:(Required)

Slope to Drain ( ¼ inch per min.):

Deck Width (4’ min. for limited use, 8' min. for limited use):(Required)

Depth markers locations at:(Required)

Gutter/Skimmer

Gutters:(Required)

Yes

Details required on plans.

Skimmer Make:(Required)

Skimmer Model No.:(Required)

NSF Approved?(Required)

Yes

Number of Units:(Required)

Throat Diameter:

Filter Information

Make:(Required)

Model No.(Required)

NSF Approved?(Required)

Yes

Number of filters:(Required)

Type of filter:(Required)

Area of filter (sq. ft.):(Required)

Total filter area (sq. ft.):(Required)

Circulation Rate (gpm):(Required)

Backwash Rate (gpm):(Required)

Turnover Rate:(Required)

Pump Information

Horsepower:(Required)

Strainer Size:(Required)

Circulating Rate (gpm):(Required)

Circulating Rate (tdh):(Required)

Disinfecting Device

Make:(Required)

Model No.:(Required)

NSF Approved?(Required)

Yes

Chlorine:

Type of Cl2:

Bromine:

Other:

Chemical Feeders

Make:(Required)

Model No.:(Required)

NSF Approved?(Required)

Yes

Other Equipment

Flow Meter Make:

Model No.:

NSF Approved?(Required)

Yes

Main Drains Quantity:

Anti Vortex?(Required)

Yes

Openings (5/8 inch max):

Inlets Quantity:

Indicate locations on plans.

Deck Lights Quantity:

Watts:

Underwater Lights Quantity:

Watts:

Diving Board Quantity:

Length:

Ladder Quantity:

Tread Width:

Lifeguard Chair Quantity:

Height:

Portable?(Required)

Yes

Ring Buoy Quantity:

Diameter:

Rope Length:

Shepherds Crook Quantity:

Length:

Test Kit Make:

Model:

Spa Controls/Timer Time Period:

Distance from spa’s edge:

Drinking Fountains Quantity:

Indicate locations on plans.

Equipment Room

Floor Finish:(Required)

Slope to drain (¼ in. per ft. min.):(Required)

Bath House

Will there be a bath house?(Required)

Yes

Tempered water temp (°F):(Required)

Enclosure

Fence Height:

Self-latching gate?(Required)

Yes

Latch Height:

Yes

Gas Chlorine Storage Room

Will gas chlorine be used?(Required)

Yes

Separate storage room?(Required)

Yes

Window in door?(Required)

Yes

Is the room vented?(Required)

Yes

Scale Supplied(Required)

Yes

Mask Provided(Required)

Yes

Pool Slides/Flumes/Water Features

Indicate if planning to be installed:(Required)

Yes

Will it be lubricated with flowing water?

Yes

Signs

Please indicate exact wording. (Most commercial signs do not meet local requirements.)(Required)