APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT

A fee of $200.00 for both an annual and seasonal permit is required with each completed application.

POOL INFORMATION:
Name of Public Swimming Pool:
Street Address of Pool Location:
City:	County:	Cleveland
Type of Public Swimming Pool: (check one)	Swimming Pool
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:	opening time	closing time
Type of Disinfection: (free chlorine, free bromine, etc.)
OWNER INFORMATION:
Name of Owner:	Email:
Mailing Address:
Contact Person:	Telephone Number:
OPERATOR (On-Site Manager) INFORMATION:
Name of Pool Operator:
Address:
Telephone Number:	Email:
Pool Operator Trained by:
APPLICATION SUBMITTED BY:
Owner or Operator:
Signature	Typed or printed name
Date:

Purpose: General Statute 130A-282 requires the commission for Public Health to adopt rules governing public swimming pool. 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.

APPLICATION AND PAYMENT CAN BE SUBMITTED IN PERSON OR BY MAIL TO:

Cleveland County Permits Office

1333 Fallston Road

Shelby, NC 28150

*** Please call 980-484-4779 to arrange for submission and payment of fees***

Rev. 12/23