Ohio Department of Health
Application For Plan Review
Public Swimming Pools and Spas
Action governed by Ohio Revised Code Chapter 3749
This application is required to be submitted with plans and the associated
fees in accordance with Chapter 3749.03(A) of the Ohio Revised Code and rule
3701-31-05(D)(3) of the Ohio Administrative Code prior to beginning work.
ODH File No. ____________________________________
County Local Health District
Project Name Designer
Street Address
Street Address
City, State, ZIP City, State, ZIP
Project Phone Number Designer Phone Number
Owner Contractor
Street Address Street Address
City, State, ZIP City, State, ZIP
Owner Phone Number Contractor Phone Number
Plan Review Fee Schedule Rev. Code A/R 2130
A. Total project cost of proposed construction and installation (includes equipment, materials, the deck,
the perimeter fence, or structures and ancillary buildings).
$
B. If the pool surface area is less than 2000 sq. ft. enter $1,662.00 for each pool.
This fee includes up to two inspections per rule 3701-31-05.
$
C. If the pool surface area is 2000 sq, ft. or more, enter $2578.00 for each pool.
This fee includes up to two inspections per rule 3701-31-05.
$
D. Special feature $1662.00 each. This fee includes up to two inspections per rule 3701-31-05.
$
E. If the cost and installation above is less than $5000.00, enter the minimum plan review fee, $832.00.
This fee includes no inspection.
$
F. A $373.00 fee will be assessed to the owner for each inspection in excess of those required in rule 3701-31-05.
$
Note - Every pool with a separate circulation system requires payment of a fee.
For equipment changes of pump, filter or disinfectant unit use, Equipment Replacement Notification report,
HEA 5234.
Total Fees
$
Individual to be contacted for questions regarding this proposal (please print).
Name Phone number FAX number
E-mail
I certify that the foregoing data is true statement of facts pertaining to this project as it is to be constructed.
Owner Date of signature
Must be signed by owner or owner’s agent must provide written authorization from owner.
The owner hereby agrees to construct the project in accordance with the approved plans and data sheets.
Please make check payable to TREASURER, STATE OF OHIO.
Mailing address Walk-in address Engineering Phone No:
Ohio Department of Health Revenue Processing Ohio Department of Health (614) 466-1390
BEH, Engineering Program Revenue Processing
246 North High Street 246 North High Street
Columbus, Ohio 43215-0278 Columbus, Ohio 43215-0278
HEA 5215 (Rev. 05/12)
Type of Project
Application Type
1.
Pool
2.
Spa
3.
Spray Ground
4.
Special Use Pool
5.
Special Feature
New
Renovation
