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Application-Public Swimming Pool Operation Permit
Address of Pool Location:
Street Address
City
State / Province / Region
Postal / Zip Code
Type of Public Swimming Pool
Swimming Pool
Wading Pool
Spa
Other (describe in field below)
Description of Other:
Date Constructed or Remodeled (check one)
Before May 1, 1993
May 1, 1993 or Later
Opening & Closing DATES of Operation
Opening & Closing TIMES of Operation
Name of Owner, Mailing Address, Contact Person AND Phone Number
Name of Pool Operator, Pool Address, Address AND Phone Number
Training Provided by & their Certificate Number
Application Submitted by (owner or operator):
First
MI
Last
Signature & Date
Clear
General Statute
Purpose: General Statute 130A-282 requires the Commission for Public Health 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, I 632 Mail Service Center, Raleigh, NC 27699-1632. (Courier 52-01-00)
Pool Drain Safety (VGB) Compliance Data
Pool Drain Safety (VGB) Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE. A separate form is required for each pumping system.
Name of Pool:
Address of Pool:
Pump Manufacturer
Pump Model Number
Pump Horsepower
Maximum Pump Flow:
Maximum flow rate from pump curve: Enter gpm in box below. (Provide supporting evidence if flow reduction)
Drain Sump Measurements:
This is the area under the floor drains, if field built sump may need to remove drain cover one time to measure. If sumpless, enter YES in box below, then proceed to next section.
Sump Shape:
If round: provide inches/width diameter
If square: provide inches X inches
Sump minimum depth INCHES
Diameter of outlet pipe in sump INCHES
Distance of top (inside) of outlet pipe from bottom of cover/grate INCHES
Sump manufacturer and model# if available
Drain Cover/Grate Data
Number of drains on each pump
Distance between drains (on centers)
Maximum flow rating of cover/grate
gpm (floor)
gpm (wall)
Date drain cover/grates installed:
Expiration Date
Equalizer Covers
Number of operable skimmer equalizers
Have the equalizers been disabled? (Yes or No)
Equalizer fitting Manufacturer
Model
Lifespan
Equalizer fitting maximum flow rating
Date equalizer cover/grates installed:
EXPIRATION DATE:
Safety Vacuum Release System (SVRS)
SVRS required if dual drains are closer than 3 feet on center or pump has a single drain with blockable cover or sump.
Safety Vacuum Release System manufacturer
Vacuum Line - Choose One
No vacuum line in pool
Protective cover on vacuum lines installed before May 1, 2010
Self-closing, self-latching cover designed to be opened with a tool on vacuum lines installed after May 1, 2010
Full name of person providing this information
First
MI
Last
Signature & Date
Clear
