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Get NC DENR 3961 2005-2024

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. 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 Swimming pool Type of public swimming pool check one 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 OWNER INFORMATION Name of owner Mailing address Telephone Contact person 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 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. 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 Swimming pool Type of public swimming pool check one 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 OWNER INFORMATION Name of owner Mailing address Telephone Contact person 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 pool owner or a designated representative of the owner. 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 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. .

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