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Swimming Pool Renewal Application


  1. 1. Application for Public Swimming Pool Operation Permit
  2. 2. Pool Drain Safety (VGB) Compliance Data
  • Application for Public Swimming Pool Operation Permit

    1. Pool Information
    2. Type of Public Swimming Pool
    3. Date Constructed or Remodeled
    4. Owner Information
    5. Operator (On-Site Manager) Information
    6. Pool Operator Trained By:
    7. Application Submitted By:
    8. Electronic Signature Agreement*
      By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
    9. 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.
    10. 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.
    11. Copies
      Original to be maintained at the local health department.
    12. Disposition
      Please refer to Records Retention and Disposition Schedule for County/District Health Departments which are published by the North Carolina Division of Historical Resources.
    13. Reorder
      Additional forms may be ordered from: Division of Environmental Health, Department of Environment and Natural Resources, 1630 Mail Service Center, Raleigh, NC 27699-1632 (Courier 52-01-00).
    14. DENR 3961 (Revised 4/03) | Environmental Health Services Section (Review 4/06)