N.C. Department of Environment and Natural Resources
Division of Environmental Health
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool:
Street address of pool location:
City:
County:
Type of public swimming pool: (check one)
Swimming pool
Wading pool
Spa
Other (describe)
Date constructed or remodeled: (check one)
Before May 1, 1993
May 1, 1993 or later
Dates of operation: opening date
closing date
Hours of operation: opening time
closing time
OWNER INFORMATION
Name of owner:
Mailing address:
Contact person:
Telephone:
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator:
Address:
Telephone Number:
______________________________
Pool operator trained by: __________________________________________________________________
(Certificate Number: )
APPLICATION SUBMITTED BY:
Owner or operator:
Signature Typed or printed name
Date :
Purpose: General Statute 130A-282 requires the Commission for Health Services to adopt rules governing public swimming pools. The rules in 15A
NCAC 18A .2500 require the owner or operator to apply annually for an operation permit for each public swimming pool. This form is to allow
owners or operators of public swimming pools to apply for permits. Preparation: The information requested on this form is to be completed by the
pool owner or a designated representative of the owner.
The completed application is submitted to the local health department for the
county in which the public swimming pool is located.
A separate application must be completed for each public swimming pool. Copies:
Original to be maintained at the local health department. Disposition: Please refer to Records Retention and Disposition Schedule 8.B.6., for
County/District Health Departments which are published by the North Carolina Division of Archives & History.. Reorder: Additional forms may
be ordered from: Division of Environmental Health, Department of Environment and Natural Resources, 1632 Mail Service Center, Raleigh, NC
27699-1632, (Courier 52-01-00)
DENR 3961 (Revised 7/05)
Environmental Health Services Section (Review 7/08)
