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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.
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.
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.
Original to be maintained at the local health department.
Please refer to Records Retention and Disposition Schedule for County/District Health Departments which are published by the North Carolina Division of Historical Resources.
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).
DENR 3961 (Revised 4/03) | Environmental Health Services Section (Review 4/06)
A separate form is required for each pumping system.
Provide supporting evidence if flow reduction.
This is the area under the floor drains, if field built sump may need to remove drain cover one time to measure.
SVRS required if dual drains are closer than 3 feet on center or pump has a single drain with blockable cover or sump.
This field is not part of the form submission.
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