HomeMy WebLinkAboutIsland Properties 500086 App 03 23 16.TIF i N.C. Department of Environmental and Natural Resources
Division of Environmental Health F1,1_061.76
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: L"a,rh0 Don S-Do_/U o
Name of public swimming pool: _C �a�� v /V�e/ �i ''S /! 55�onc;cc / 4,9
Street address of pool location: 1/es-2- /1 / 5 c r a-3 for,/ ✓pct
City: County: e✓/e-l/ CLcau///ct
Type of public swimming pool(check one) X Swimming pool RECEIVED
❑ Wading pool MAR 2 3 2016
❑ Spa
CATAWBA. COUNTY
❑ Other (describe) ENVIRONMENTAL HEALTH
Date constructed or remodeled: (check one) ❑ Before May 1, 1993 �/ q / �J
May 1, 1993 or later /it Magdd
Dates of operation: opening date /7761.2- // 2-0(Z closing date C 2-67/6
Hours of operation: opening time 7/ 4 closing time /1,121n-
OWNER INFORMATION: D
Name of owner: ..LS�c�d // d ✓e e-rzl///e-�5 /
(r l.,,/ ailing address: to 3S !I a ��O�'� /4J�) C-�ar�t e� N` �r Ill—Contact person: /J / 1/ S ter Telephone: 7 a `f— / c I —G 7
OPERATOR(On-Site Manager) INFORMATION:
Name of pool operator: ST; A A/ 6,—c_c✓
Address: Po . / 94, e✓✓e/� /r/( . Zi leeZ
Telephone number: gle ` - - i 5-6 .- q 3 3 7
Pool o erator trained by: (check one) Si National Swimming Pool Foundation
5 15 ed i/Gc 2 Eel (Certificate Number: 0/7�/� 7(7 )
-)a if- 5 3o - 36 z3
❑ Other(please specify)
APPLICATION Sil T ED BY/: A / N�
/ 79- Je%AN /!/` �c_ef(y.
Owner or operator: /
ature Typed or pr'nted name
Date: 3/ 2-112--C /e
Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The roles in 15A
NCAC 18A2500 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 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)
(1,-;A:,-. .\ CATAWBA COUNTY
Ipt IOOA SOUTHWEST BLVD
5 r Z NEWTON, NORTH CAROLINA 28658 RECEIPT
'" PI-ZONE: 828 465.8399
\U\�' •1!5 / Wednesday, March 23, 2016
\ Jw�
�84'L sm www.catawbacountync.gov
PAYOR: ISLAND PROPERTIES HOMEOWNERS ASSOC
ISLAND PROPERTIES HOMEOWNERS ASSOC
PAYMENTS
TRANSACTION NUMBER: TRC-642669-23-03-2016
PAYMENT DATE : 03/23/2016
PAYMENT TYPE: Check 2399
received by mail
INVOICE NUMBER FEE NAME F EE AMOUNT
03-16-326415 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : S150.00
FLT-0000170
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 4838 KISER ISLAND RD CT,TERRELL NC
Applicant DEFAULT APPLICANT„
Manager ISLAND PROPERTIES HOMEOWNERS ASSOC, 208 PAYNE LN, CLEMSON SC 29631
OTHER-IMPORTED ISLAND PROPERTIES, 208 PAYNE LN, CLEMSON SC 29631
F:NONE NONE
Owner ISLAND PROPERTIES OWNERS ASSOC INC, 208 PAYNE LN, CLEMSON SC 29631
receipt 03/23/2016 14:42 Page 1 of 1