Ohio Department of Health Public Swimming Pool Equipment Replacement Notification Report Action governed by Ohio Administrative Code Chapter 3701-31 County Local health department Project name Owner Street address Street address City ZIP City State ZIP Project phone number Owner phone number ( ) ( ) Instructions:

1. a. Print clearly and complete both sides.
2. b. Use only one form for equipment changes you propose for each public swimming pool, spa, or special use pool.
3. d. Other substantial alterations requiring more extensive plan review shall be submitted with plans and a completed Application for Plan Review, HEA 5215.
4. e. All equipment shall be listed with NSF, ETL, or as approved by the Director. Changes to equipment, including the use of additives or substitute materials/reagents/chemicals that affect equipment performance and are not authorized by the manufacturer affect the product listing; accordingly, such substantial alterations must be authorized.
5. I. Equipment Replacement Plan Review Fee Schedule -Replacement of a disinfection reagent feed device with a different method of delivery, different reagent, or that changes the disinfectant output; -Replacement of a circulation filter with a different size, different method of filtration, or different media, or a different method of operation; -Replacement of a circulation, jet, or special feature pump that changes the operation of the pool or associated equipment; -Replacement of a vacuum limit switch (VLS):

ALL are substantial alterations requiring plan review using this form. The plan review fee is forty dollars. $ NOTE: Replacement of an Automatic Chemical Controller or of a pH reagent feeder is not a substantial alteration. Replacement equipment which is identical to the design and operation of the original and previously approved equipment is considered as maintenance and repair. II. Pool, Spa, Special Use Pool Design (existing) 01 Specifications

1. a. Pool/Spa Volume gal
2. b. Required Turnover Period a Pool—480 min (8 hr) a Wading Pool—120 min (2 hr) a Spa—30 min (1/2 hr) a Special Use Pool—240 min (4 hr) a Other
3. c. Required Flow Rate (1a / 1b) gpm
4. d. Actual Flow (as measured by a flow measuring device) gpm

III Equipment Replacement 02 Disinfection # a) Disinfectant b) Manufacturer/ Make c) Model # d) Output Existing a Calcium Hypo a Sodium Hypo a gals/d a Di/Tri-chloro a Bromine a NaCl a lbs/d a Erosion Other: a grams/d Replacement a Calcium Hypo a Sodium Hypo a gals/d a Di/Tri-chloro a Bromine a NaCl a lbs/d a Erosion Other: a grams/d NOTE: Change from one disinfectant to another within the same disinfectant feeder is still an alteration requiring plan approval. 03 Filtration # a) Media b) Manufacturer/ Make c) Model # d) Total Filter Area (sf) e) Max. Allowable Filter Flow (gpm) Existing a Vacuum a Press.

a Sand a DE a Cartridge Replacement a Vacuum a Press.

a Sand a DE a Cartridge NOTE: 1. Changing filter media within the same filter unit is an alteration requiring approval.

1. 2. Flow through a filter shall not exceed the rated capacity (see 03e)
2. 3. Filters in parallel shall all be of equal size/capacity.

Replace equipment

HEA 5234 (05/04)

Type a Outdoor a Indoor a Pool a Dive Well a Wading pool a Spa Special Use Pool Special Feature a Flume slide a Kiddee slide a Rec. slide a Rain drop a Speed slide a Wet Deck a Drop slide Other ODH File No.

04 Pumps: Circulation, Jet/Hydrotherapy, Special Features, Air # a) Manufacturer/ Make b) Model # c) Horsepower d) Total Dynamic Head e) Capacity (gpm) (Ft)-if known Existing Replacement The following criteria shall apply:

1. a. Provide a pump curve and other applicable design specifications.
2. b. A replacement circulation pump shall provide, at minimum, the flow rate as indicated in 01(c), above.
3. c. There shall be no significant increase in any pump capacity without approval to prevent a potential entrapment hazard.
4. d. To avoid a shock hazard air pumps shall be installed on a wall or with a vertical loop of pipe, both, 12 inches or more, above the operating water level of the spa/special use pool. 05 Vacuum Limit Switch # a) Manufacturer/ Make b) Model #

Existing Replacement Provide a copy of the installation diagram 06 Automatic Chemical Controllers (required on all public spas and some special use pools with special features) Note: replacement of an automatic controller is not a substantial alteration; however, the installation shall be in accordance with rule 3701-31-07. 07 Pipe Pipe used for maintenance or repair work or as part of equipment installation shall be according to the following standard or equivalent: PVC, Schedule 40 or 80, ASTM D 1785 (of equal diameter or greater) and with compatible PVC fittings: ASTM D 2446 or D 2447. Note: The above information will be forwarded to the local health district to verify the installation after approval. IV Remarks Individual to be contacted regarding this project (please print) Applicant Phone Fax I certify that the foregoing data is a true statement of the facts pertaining to the above proposed work and agree to properly install the above equipment according to manufacturer specifications or as approved.

For any questions concerning this form please contact: Ohio Department of Health, Environmental Engineering, (614) 466-1390 Note: Review will not proceed nor will approval be granted without complete submission of all information. Please make check payable to: Treasurer, State of Ohio Send this form and check to:

Mailing address: Walk-in address:

Ohio Department of Health Ohio Department of Health Revenue Processing Unit Revenue Processing Unit Public Swimming Pool Plan Review Fees 1st Floor P.O. Box 15278 246 North High Steet Columbus, OH 43215-0278 Columbus, OH