Fillable Application For A Recreational Water Facility (Island Health)

Fill Online, Printable, Fillable, Blank Application For A Recreational Water Facility (Island Health) Form

Use Fill to complete blank online ISLAND HEALTH pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application For A Recreational Water Facility (Island Health)

On average this form takes 22 minutes to complete

The Application For A Recreational Water Facility (Island Health) form is 1 page long and contains:

  • 0 signatures
  • 50 check-boxes
  • 66 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your Island Health forms online.

BROWSE ISLAND HEALTH FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
APPLICATION FOR RECREATIONAL WATER FACILITY
COMPLETE ONE APPLICATION IN FULL FOR EACH POOL IN YOUR FACILITY
The personal information collected relates directly to and is necessary for program operation per Section 26 of the Freedom of Information and Protection of Privacy Act. Information
that appears on a licence may be disclosed per Section 22(4)(i) of the Act, as it is not considered an unreasonable invasion of personal privacy. If you have any questions about the
collection and use of this information, contact the Vancouver Island Health Authority Information & Privacy Office at (250) 370-8043.
PLEASE PRINT WHERE POSSIBLE
Health Protection
STATUS
NEW
New Facility
New Location
New Ownership
Change to Facility
RECREATIONAL
WATER
FACILITY
FACILITY NAME_________________________________________________________________________________________________
FACILITY LOCATION ADDRESS_____________________________________________________________________________________________________
CITY____________________________________________________________________POSTAL CODE___________________________________________
TELEPHONE_____________________________FAX____________________________EMAIL___________________________________________________
SEND INVOICE TO SAME AS FACILITY OR:________________________________________________________________________________________
FACILITY’S
REGISTERED
OWNER(S)
OR
LEASEE(S)
REGISTERED OWNER/LEASEE NAME_______________________________________________________________________
MAILING ADDRESS_______________________________________________________________________________________
CITY________________________________PROV_________________________________POSTAL CODE__________________
TELEPHONE____________________________ FAX_____________________________EMAIL__________________________
ALTERNATE PHONE______________________________________________________________________________________
SOCIETY
SOLE PROPRIETOR
PARTNERSHIP
INCORPORATED
FACILITY
MANAGER /
CONTACT
CONTACT NAME________________________________________________________________________________POSITION________________________
ADDRESS_______________________________________________________________POSTAL CODE___________________________________________
TELEPHONE_____________________________FAX_____________________________EMAIL__________________________________________________
BUILDING
INFORMATION
BUILDING NAME (IF DIFFERENT FROM FACILITY)_____________________________________________________________________________________
ADDRESS____________________________________________________________CITY_____________________________POSTAL CODE_____________
OWNER OF
BUILDING OR
COMPLEX
REGISTERED NAME______________________________________________________________________________________
MAILING ADDRESS_______________________________________________________________________________________
CITY____________________________________________PROV_____________________POSTAL CODE_________________
CONTACT/AGENT NAME ______________________________________________________POSITION_____________________
TELEPHONE_____________________________FAX_______________________________EMAIL________________________
SOCIETY
SOLE PROPRIETOR
PARTNERSHIP
INCORPORATED
FACILITY
SERVICING
WATER SOURCE COMMUNITY SYSTEM NAME_____________________________________________________________ WELL
SEWAGE DISPOSAL SEWER ONSITE SEWAGE DISPOSAL
OPERATIONAL
MONTHS
NUMBER OF MONTHS OPEN OR OPERATING WHICH MONTHS
DURING YEAR (INCLUDE PARTIAL MONTHS)____________________ ALL YEAR
POOL
DETAILS
(COMPLETE
SECTIONS 1, 2 & 3)
1) DIMENSIONS
SURFACE
AREA___________m
2
MAX.
DEPTH__________m
POOL ≥ 19 m
2
POOL < 19 m
2
POOL < 61 cm DEEP
POOL ≥ 61 cm DEEP
2) POOL TYPE
PUBLIC WADING
COMMERCIAL SPRAY
HOT TUB
3) ADDITIONAL FEATURES OF POOL
INDOOR OUTDOOR
WATER SLIDE MOTION POOL
OTHER________________________________
ADDITIONAL
SYSTEM
INFORMATION
FILTRATION TYPE SAND DIATOMACEOUS EARTH (D.E.) OTHER_________________________________
DISINFECTION TYPE CHLORINE BROMINE OZONE UV OTHER______________________
DOES YOUR FACILITY USE GASEOUS CHLORINE? YES NO DOES THE POOL OPERATOR HAVE APPROPRIATE TRAINING? YES NO
HAS A POOL SAFETY PLAN BEEN COMPLETED? YES NO HAS A CONSTRUCTION PERMIT APPLICATION BEEN SUBMITTED? YES NO
VERIFICATION
APPLICANT SIGNATURE__________________________________________________________________
I hereby certify that the information set out by me in this application is true and correct to the best of my knowledge and belief.
I acknowledge that it is an offence to supply false or inaccurate information on this application.
PRINT NAME_____________________________________________________POSITION______________
PHONE___________________ ADDRESS___________________________________________________
DATE_______DD / MMM / YYYY
______________________________________
PROPOSED OPENING DATE
FOR
OFFICIAL
USE ONLY
DATE
INITIALS
APPLICATION PACKAGE REC’D
FACILITY TYPE
CONSTRUCTION PERMIT ISSUED
FACILITY #
FACILITY APPROVED BY E.H.O.
AMOUNT PAID
POSTED TO HEALTHSPACE
METHOD OF PAYMENT
OPERATING PERMIT SENT
RECEIPT #
H:\RECREATIONAL WATER\FORMS\RECREATIONAL WATER FACILITY – February, 2012 WHITE COPY – HEALTH AUTHORITY YELLOW COPY – APPLICANT
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application For A Recreational Water Facility (Island Health)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 25 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document