HomeMy WebLinkAboutHickory YMCA App 550013 11 04 09.tif
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N.C. Department of Environmental and Natural Resources
Division of Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: ( ,n
Name of public swimming pool: tG" CZ[
Street address of pool location:
City: County: C G-~n L^~
Type of public swimming pool (check one) ❑ Swimming pool
❑ Wading pool
V 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 Q
Hours of operation: opening time closing time /
OWNER INFORMATION: (~~0Q ~ I.
Name of owner: C iiicl-,f ~ l~lC;.`~c on ~ ~Ac
Mailing address: CJ IS''1 ~-t . A ~j
Contact person: , n 7p V"CM Telephone: S2,--t 21-E-ff
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator:Y
Address: 1 G ,S~ N
Telephone number: ~2A Z~S
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:
Other (please specify)
APPLICATION SU 'IIMTIBI Y • ~
Owner or operator: /ly 15:):- n Fes '
0
Signalure Typed or printed name
Date: / G 1.~ 1 In 9
Purpose General Statute 130A-282 requires the Commission 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. 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 for County/District Health
Departments which are published by North Carolina Division of Historical Resources. Reorder: Additional Dorms 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) 1 I
Environmental Health Services Section (Review 4/06) C1_1 V CW
A
$ COQ CATAWBA COUNTY, NC
10 South West Blvd
Newton, ~ERMIT IrlY OI CE
Newton, NC 28658-
Phone: (828)465-8399
Wednesday, November 4, 2009
1 Z www.catawbacountync.gov
84 sM
Permit Number: FLI-0000203 Invoice Number: FLI-11-09-256965
Permit Type: Food & Lodging Institutions Receipt Number: RCPT-000432
Work Class: 55 - Year-Round Spa
Address: 701 1 ST ST NW, HICKORY,
AIPPL I C ANT
OW rO~ R - j
INIP.ORT=AP,P I'I:It\111 l)I 1-.A1.iL"I'r~[ PLI~.1ti1 MENS',YOUNG
PO' BOX 280
CONOVER NC 28613`
FFF DESCRIPTION DATE FF,F AMOUNT
Pool In..oecu0u 1'ce - 1 1/19/2007 ~?f)CI.1)O s
Pool lnz bectlon Fee
11 /04/2009'=
001 Fee's 03/28/2008 0000
S-2
,Pool'Inslection Fee '10/28/2008 `S200.00
TOTAL FEES $800.00
Date Payment Type Check Number Amount Change
11104/2009 Check 054436 $200.00 $0.00
Memo: NGDL.) 1151593
Total Payment: $200.00
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