HomeMy WebLinkAboutDays Inn Pool 500100 App 03 22 16.TIF FLf a-
N.C. Depafhnent of Environment and Natural Resources
Division of Environmental Health ZO) I Do
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: �� s /��
Name of public swimming pool: / v ��i Nt "�} "� S LU 1 ' KT CA DA y
Street address of pool location: X 25
)377-1 )I V 2%1 HiC,0$ f , Al( - 2S/6 0 )
City: f I CkOA f County: (4T)g- tvB "7
Type of public swimming pool: (check one) Swimming pool
n Wading pool
❑ Spa
n Other (describe)
Date constructed or remodeled: (check one) ❑ Before May 1, 1993
/� n May 1, 1993 or later
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Dates of operation: opening date 5fri closing date 69CT -3 / r 20/g
Hours of operation: opening time / 0 '9 ZVI closing time / 0P
OWNER INFORMATION
Name of owner: 'I A15 SW21&S
Mailing address: 12-5 )31/1 1)'m i-DA N-,t/d, N2(KO/z'l, NC- 2-StO/
Contact person: zTE-e- Ti}Ai iS Telephone: -4-3) ` 2 10 0
OPERATOR (On-Site Manager) INFORMATION: C e(/' g2 y"E38`-(D 4-0
Name of pool operator: 0--enOi;-5 0A �� L
Address: ) J 2 5 13 (1 5- 4< N-1/1/. 11100A-7/ 1C- 2 rho/
Telephone Number:
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:
❑ Other (please specify)
APPLICATION SUBMITTED BY:
Owner or operator: _`) / ' � �) )e c
Signature Typed or priiwed name- -- •/
i Date: 0 3
Purpose:General Statute 130A-282 requires the Commission for Health Services to adopt rules governing public swimming pools. The rules in 15A
NCAC I8A .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 the North Carolina Division of Historical Resources. Reorder: 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)
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�p'A Cp CATAWBA COUNTY
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100A SOUTHWEST BLVD
NEWTON, NORTH CAROLINA 28658 RECEIPT
PHONE: 828.465.8399
1P-9,441414E'' Tuesday, March 22, 2016
1842 srr www.catawbacountync.guy
PAYOR: DAYS INN POOL
DAYS INN POOL
PAYMENTS
TRANSACTION NUMBER: TRC-642004-22-03-2016
PAYMENT DATE : 03/22/2016
PAYMENT TYPE: Check 1253
INVOICE NUMBER FEE NAME FEE AMOUNT
03-16-326368 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-07-2013-039542
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 1725 13TH AV DR NW, HICKORY NC 28601
Owner DAYS INN POOL, 1725 I3TH AV DR NW, HICKORY NC 28601
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Pool Operator JASON SETZER. 1725 13TH AV DR NW, HICKORY NC 28601
B:8284312100
receipt 03/22/2016 13:26 Page 1 of 1