Advanced Notification for Seasonal Operation

Must be Submitted 45 Days Prior to Opening Each Year

(15A NCAC 18A .1000, .3600, .3500)

Type of Camp:	Summer Camp	Resident Camp	Primitive Experience Camp
Date Submitted:
Dates of Operation:	to	or	Calendar Schedule Attached
Name of Camp:
Physical Address of Camp:
City:	State:	NC	Zip:	Phone #:
Name of Owner/Agency:
Billing Address:
City:	State:	NC	Zip:	Phone #:
Camp Contact (Name of the responsible person):
Contact Phone #:	Cell #:
Contact Email:
Type of Water Supply:	Municipal/Public Community	Non-Community or Non-Public
If Non-Community or Non-Public water supply, what date will the water supply well(s) be
accessible for sampling and inspection?
Type of wastewater system:	Public sewage treatment plant	Individual sewage disposal system
If individual sewage disposal system, permit #:	DEQ permit or DHHS permit
Max capacity of the camp:	# of campers	# of staff:
Date:	, prior to the first date of operation, when facilities will be inspected by camp
management to ensure that:
A. Camp facilities are clean and in good repair.
B. Camp kitchen equipment, including required refrigeration and dishwashing equipment, is clean and operational.
C. Camp buildings and permanent sleeping quarters are free from all bats and other vermin, wildlife, and pest harborages.
D. The camp is free from conditions which represent a threat to public health.
Are there swimming pools, wading pools, or water recreation attractions at the camp? Yes No
If yes, please list:
Field sanitation: Written procedures available at inspection Does not apply.
Name of Person completing the form:	Title:
Signature:	Date:
By signing this form, I certify the information I provided on this form is true and correct to the best of my knowledge.

Applications can be submitted in person or by mail to:

Cleveland County Permits Office

1333 Fallston Road

Shelby, NC 28150

Rev. 5/24