DHEC Form 3627 "Swimming Pool Change Order Request Form" - South Carolina

What Is DHEC Form 3627?

This is a legal form that was released by the South Carolina Department of Health and Environmental Control - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Environmental Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DHEC Form 3627 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Environmental Control.

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Download DHEC Form 3627 "Swimming Pool Change Order Request Form" - South Carolina

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Swimming Pool Change Order
Request Form
Drinking Water Protection Division
*PLEASE TYPE OR PRINT CLEARLY
DATE (MM/DD/YYYY):
Total # Pages Included:
Section 1. Contact Information
SENDER NAME:
FACILITY OWNER:
COMPANY NAME:
PRIMARY CONTACT:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
ZIP:
PHONE NUMBER:
FAX NUMBER:
PHONE NUMBER:
FAX NUMBER:
EMAIL:
EMAIL:
Section 2. Facility Information
PERMIT #:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
A
B
C
D
E
F
G
COUNTY:
POOL TYPE (choose one):
Pool Surface Area (ft
):
2
Pool Volume (gallons):
Recirculation flow (GPM):
Section 3. Project Description
(if more space is required, use the back of this sheet or attach extra pages)
No
Is this Project cost $5000.00 or greater? (choose one):Yes
If Yes provide LLR Contractor License #:
Are additional plans or sketches attached with this request?
( choose one ):
NO
YES
Section 4. Equipment Change Information
PROPOSED EQUIPMENT
:
EXISTING EQUIPMENT
:
(Make & Model #)
(Make & Model #)
Disinfection Equipment:
Pump Make & Model:
No. of Pumps:
Filter Make & Model:
No. of Filters:
*PLEASE NOTE: IF CHANGE ORDER REQUEST INVOLVES PIPING OR STRUCTURAL CHANGES, STAMPED ENGINEERING
DRAWINGS MUST BE SUBMITTED.
Signature of Sender:
**THIS AREA FOR DEPARTMENT USE ONLY**
Is this change order approved? (choose one)
YES
NO
Are there any special conditions? (choose one)
YES
NO (if yes, see attached)
Department Signature:_____________________________
Date:____________________
This change order is valid for one year from the approval date.
*PLEASE NOTE: A final inspection is required prior to operation. When modifications have been completed, contact
_________________________________ at ( _____ )
________
3 days prior to scheduling the inspection.
DHEC 3627 (01/2020)
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Swimming Pool Change Order
Request Form
Drinking Water Protection Division
*PLEASE TYPE OR PRINT CLEARLY
DATE (MM/DD/YYYY):
Total # Pages Included:
Section 1. Contact Information
SENDER NAME:
FACILITY OWNER:
COMPANY NAME:
PRIMARY CONTACT:
ADDRESS:
ADDRESS:
CITY:
CITY:
STATE:
ZIP:
STATE:
ZIP:
PHONE NUMBER:
FAX NUMBER:
PHONE NUMBER:
FAX NUMBER:
EMAIL:
EMAIL:
Section 2. Facility Information
PERMIT #:
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
A
B
C
D
E
F
G
COUNTY:
POOL TYPE (choose one):
Pool Surface Area (ft
):
2
Pool Volume (gallons):
Recirculation flow (GPM):
Section 3. Project Description
(if more space is required, use the back of this sheet or attach extra pages)
No
Is this Project cost $5000.00 or greater? (choose one):Yes
If Yes provide LLR Contractor License #:
Are additional plans or sketches attached with this request?
( choose one ):
NO
YES
Section 4. Equipment Change Information
PROPOSED EQUIPMENT
:
EXISTING EQUIPMENT
:
(Make & Model #)
(Make & Model #)
Disinfection Equipment:
Pump Make & Model:
No. of Pumps:
Filter Make & Model:
No. of Filters:
*PLEASE NOTE: IF CHANGE ORDER REQUEST INVOLVES PIPING OR STRUCTURAL CHANGES, STAMPED ENGINEERING
DRAWINGS MUST BE SUBMITTED.
Signature of Sender:
**THIS AREA FOR DEPARTMENT USE ONLY**
Is this change order approved? (choose one)
YES
NO
Are there any special conditions? (choose one)
YES
NO (if yes, see attached)
Department Signature:_____________________________
Date:____________________
This change order is valid for one year from the approval date.
*PLEASE NOTE: A final inspection is required prior to operation. When modifications have been completed, contact
_________________________________ at ( _____ )
________
3 days prior to scheduling the inspection.
DHEC 3627 (01/2020)
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Purpose:This form is to be used by contractors, builders, engineers, architects, and any other party
responsible for making changes to a public swimming facility in the state of South Carolina.
This application must be submitted to the following address:
South Carolina DHEC
Drinking Water Protection Division
Construction Permitting Section
2600 Bull St.
Columbia, SC 29201
ITEM BY ITEM INSTRUCTIONS FOR COMPLETING THIS FORM:
Enter the date in the first space. Enter the total number of pages included in the space to the right.
SECTION 1. CONTACT INFORMATION
In the left column of section 1, enter the SENDER’s information including: name of sender, company
name, address, city, state, zip, phone number, fax number and email address.
In the right column of section 1, enter the FACILITY OWNER’s information including: name of facility
owner, primary contact name, address, city, state, zip, phone number, fax number and email address.
SECTION 2. FACILITY INFORMATION
In section 2, enter the FACILITY’s information including: name of facility, address, city, state, zip.
In section 2, enter the FACILITY’s pool information including: permit number, county, the pool
type (A, B, C, D, E, F, G), pool surface area, volume, and recirculation flow.
SECTION 3. PROJECT DESCRIPTION
Using the space provided, describe the proposed changes to the swimming facility. Check (YES or NO)
on if this project cost $5,000.00 or more. If Yes include LLR contractor license number. Check (YES or
NO) whether additional plans or sketches are attached to the change order request.
SECTION 4. EQUIPMENT CHANGE INFORMATION
In the left column of section 4, enter the make and model of the proposed equipment.
In the right column of section 4, enter the make and model of the corresponding existing equipment.
For projects beyond replastering and/or deck work, please provide the pump, filter, and disinfection
equipment make and model.
REMEMBER TO SIGN AT THE BOTTOM. ALL SIGNATURES MUST BE ORIGINAL.
Office Mechanics and Filing: This form should be filed in the Recreational Waters File Room according
to facility permit number.
DHEC 3627 (01/2020)
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