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2. Name of public swimming pool*
3. Street Address of pool location*
5. City*
6. County*
8. Type of public swimming pool*

   1. Swimming Pool
   2. Wading Pool
   3. Spa
9. Other (Please Describe)*
10. Date Constructed or Remodled*

    1. Before May 1, 1993
    2. May 1, 1993 or later
11. Dates of Operation*
    Dates of Operation Start Date

    Dates of Operation Start Time

    —

    Dates of Operation End Date

    Dates of Operation End Time
13. Owner Information
15. Name of Owner*
16. Mailing Address*
18. Contact Person*
19. Telephone Number*
21. Operator (On-Site Manager) Information*
22. Mailing Address*
24. Telephone Number*
25. Pool Operator Trained by*
26. Certificate Number*
28. Application Submitted by*
29. Date
    Date
31. 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: Environmental Health Section, Department of Health and Human Services, 1632 Mail Service Center, Raleigh, NC 27699-1632.
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33. Submit Submit and Print

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