"Pool, SPA, and Aquatic Features Variance Request Form" - Wyoming

Pool, SPA, and Aquatic Features Variance Request Form is a legal document that was released by the Wyoming Department of Agriculture - a government authority operating within Wyoming.

Form Details:

  • Released on October 5, 2018;
  • The latest edition currently provided by the Wyoming Department of Agriculture;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Wyoming Department of Agriculture.

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Consumer Health Services
Phone: (307) 777-7211
Web: agriculture.wy.gov
The Wyoming Department of Agriculture is dedicated to the promotion and enhancement of Wyoming’s agriculture, natural resources and quality of life.
Pool, Spa, and Aquatic Features Variance Request Form
Name of Establishment: __________________________________________
Date Submitted: ___________________________
Name of Agent or Applicant: ____________________________________________________________________________________
Street Address: ___________________________________________________
City: ______________________________________
State: ___________________________
Zip: ________________
Telephone: _________________________________
Name of Project Contact : _________________________________________________________________________________
Street Address: ___________________________________________________
City: _______________________________________
State: ____________________
Zip: ______________
Telephone: ______________________
Name of Contractor: ____________________________________________________________________________________________
Street Address: ___________________________________________________
City: _______________________________________
State: ____________________
Zip: ______________
Telephone: ______________________
License Number: ______________
Cite all relevant regulations ( from the Wyoming Regulations for Swimming Pool, Spas and Aquatic Features) for the proposed
variance.
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Statement of the proposed variance. Attach a copy of application, drawings, specifications, photos, etc., that clearly illustrate this
variance request. (Attach separate sheet if necessary.)
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Consumer Health Services
Phone: (307) 777-7211
Web: agriculture.wy.gov
The Wyoming Department of Agriculture is dedicated to the promotion and enhancement of Wyoming’s agriculture, natural resources and quality of life.
Pool, Spa, and Aquatic Features Variance Request Form
Name of Establishment: __________________________________________
Date Submitted: ___________________________
Name of Agent or Applicant: ____________________________________________________________________________________
Street Address: ___________________________________________________
City: ______________________________________
State: ___________________________
Zip: ________________
Telephone: _________________________________
Name of Project Contact : _________________________________________________________________________________
Street Address: ___________________________________________________
City: _______________________________________
State: ____________________
Zip: ______________
Telephone: ______________________
Name of Contractor: ____________________________________________________________________________________________
Street Address: ___________________________________________________
City: _______________________________________
State: ____________________
Zip: ______________
Telephone: ______________________
License Number: ______________
Cite all relevant regulations ( from the Wyoming Regulations for Swimming Pool, Spas and Aquatic Features) for the proposed
variance.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Statement of the proposed variance. Attach a copy of application, drawings, specifications, photos, etc., that clearly illustrate this
variance request. (Attach separate sheet if necessary.)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
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An analysis of the rationale for how the potential public health and safety hazards and nuisances addressed by the relevant Regulation
sections will be alternatively addressed by the proposal. State reason and justification as to why the variance would relieve the non-
compliance of the rule. (Attach separate sheet if necessary.)
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State any additional reason or provide any technical documentation to support your supposition that a variance would not likely result
in an impairment to public health. (Attach a separate sheet if necessary.)
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A FINAL LETTER OF APPROVAL OR DENIAL WILL BE SENT TO THE AGENT, APPLICANT AND OR ESTABLISMENT BY THE CONSUMER
HEALTH SERVICES (CHS) MANAGER.
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Signature of Agent or Applicant
Date of Application
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FOR ADMINISTATION USE ONLY.
Date received: ___________________________________
Jurisdiction: _____________________________________
Date reviewed: __________________________________
County: _________________________________________
☐Variance APPROVED
☐Variance DENIED with comments
Comments:_________________________________________________________________________________________
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CHS Manager Signature: _________________________________________
Date: __________________________
Form Fit for use: ___
_____________________ Date:__ 10/05/2018______________________
CHS Manager
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