Mecklenburg County Health Department
APPLICATION FOR RESIDENTIAL POOL CONSTRUCTION
(All Sections of this Application Must Be Completed AND Signed for Processing)
Physical street address of installation: _____________________________________________________________
Subdivision Name:_____________________________City: _____________________________Zip Code: ____________
Owner: ___________________________________________ Home Phone: ______________________
Mailing Address: ____________________________________ Work Phone: ______________________
City: _______________________________ State: ________ Zip Code: ___________________
Contractor: ______________________________________________________ Phone:__________________
Contractor Charge Account: _________________________________________________________________________
Mailing Address: __________________________________ City: ________________________ State/Zip: ______________
1. Type of Water Supply(check one): City (Municipal) Private utility (Community) Private Well
2. Type of Sewage Disposal (check one): City (Municipal) Private utility (Community) Septic system
3. All outdoor residential swimming pools and spas in Mecklenburg County are required to be completely fenced or
protected once the pool is holding water. The minimum fence/barrier required by APPENDIX G of the NC
Residential Code is 48”(inches) with no opening greater than four(4) inches through the barrier or more than
2”(inches under the barrier. Gates, when provided, must be self-closing, self-latching, and, where applicable
lockable. Other requirements may apply. NOTE-driveway gates, when installed as part of the fence above, must
be installed w/ automatic self-closers.
4. Attach a scale drawing showing the proposed location of the pool and any buildings, wells, or septic tank
systems within 100 feet of the proposed pool.
MUST BE COMPLETED BY HOMEOWNER OR LEGAL(POWER OF ATTORNEY) REPRESENTATIVE
I ____________________________________________________, owner of the property, agree to the following
requirements: (initials are required beside each item listed.)
I certify that the application and site drawing being submitted are accurate and complete. _______
I hereby authorize agents of the Health Dept. to enter onto the above property to process this request and to conduct
a fence and gate inspection of the pool, when requested or needed. _______
I understand that the pool must be protected by a fence and gate(s) (or equivalent, if above ground) as specified in
the NC Residential Code, APPENDIX G and the Mecklenburg County Health Ordinance Rules Governing Residential
Swimming Pools and must be installed and completed once the pool is capable of holding water _______
Signed: ______________________________________________________ ________________
Property Owner’s Signature Date
This area for MCHD use only:
Amount Paid: $
______________ Cash Check Contractor Account
Check Number: ______________ Date: ____________ By: _________________________________________
Request #: _______________ Parcel ID#: ____________________ EHS: _________________________________
Approved By: __________________________________________ Date: __________ CRT: _________________
Disapproved By: ________________________________________ Date: __________ Notify Date: ____________
Final/Fencing Inspection By: _______________________________ Date: __________
Signature on the “Approved By” line above by an employee of the MCHD indicates Health Department approval of this application and the
accompanying site plan. All approvals are contingent upon the pool being operated in a manner that does not create a public health nuisance or
hazard, and completion of the required pool barrier at the time the pool is capable of holding water. Revised Feb 2011
By signing in this block, the contractor authorizes the processing fee for this request to be charged to their LUESA Contractor Account.
_____________________________________________________________________________________________________ ____________
NAME(PRINT) Signature Date
________________________________
