HomeMy WebLinkAboutAdrian L Shuford App 550014 04 04 16.TIF I • 061
20 c ►
N.C.Departmentof Environmental and Natural Resources
Divisionof Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
' POOL INFORMATION:
Name of public swimming pool: /ikcu.n L Sk•ute(VI .)r. 1oi- (,,t,.
Street address of pool location: 11L\i( eo•n- arr tz Ve.-t
City: County: lonOv tit
Type of public swimming pod (checkone) — Swimming pool
_/Wading pool
✓ Spa
Other(describe)
Datect mstrtictedor remodeled:(checicone) _/Before MayI,1993
l� ((�May 1,1993 or later
Dates ofoperation: opening date � `rair Mimes 3` dosing date
Hours of operation: opening time '5:0'0 A/11 closing time 'Y.0O "FA
OWNER INFORMATION: f
Name of owner: `t.Iti1GA of Gd>\w6.t \)„kje•f
Mailing address: 1.1-1 S 1,1Z i3(uc\ W bri .- 2 S 1907-
Contact person: 0.1 C`4eh°` Telephone: �in' L1U`i u�30
OPERATOR(On-Site Manager) INFORMATION::`
Name ofpool operator: ekoit iNhe Cr
Address: '2)504 5sA4en 51 (,eq$(r AM- CP-115
Telephone number: _(_Q Z ) s i -t b 4 t.r
Pool operator trained by:(checkone) fl National Swimming Pool Foundation
ri (Certificate Number: t1.2 A (92201 11 1.
✓ Other(please specify) ;VC C PO
APPLICATION SUBMITTED BY: c� , / d G//
Owner or operator:. ----' 7 G..//� �h!'%t-. M'c�'✓` `
Siguatlue 'Typed or 1 ri(ited untie
Date: L�Jcl�rb'
PurposeGeneralStatule 130A-282 requlrestheComrhission Health Servicestoadopl Riles governing publtcswimming pools.The rules 5115A
NCAC 1 SA.2500 require the owner or operator to apply annua Ily for an operation permit for each public swimming pool.This form is to allow
owners or operatorsof public swimming pools to apply for permits.Preparation:The Information requested on this farm is to be completed by the
pool owner or a designated representative of the owner,The completed epllio.Mlon 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 pubic 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 Hlstedcal Resources.Reorder:Additional Forms maybe ordered from:Division
of Environmental Health",Department of Environment and Natural Resources,1630 Mall Service Center,Raleigh,NC 27699-1632.(Courier 52-
01-00)
DENR 3961(Revised 4/03)
Environmental Health Services Section(Review 4/06) i
K?,1s..
CATAWBA COUNTY
jai }, •�� IOOASOUTHWESTBLVD
�t NEWTON,NORTH CAROLINA 28658 RECEIPT
i< �-�p�"`"44-t`. PHONE: 828.465.8399
/U 11T ri 'C Monday, April 4, 2016
842 sM www.catawbacountync.gov
PAYOR: YMCA OF CATAWBA VALLEY
YMCA OF CATAWBA VALLEY
PAYMENTS
TRANSACTION NUMBER: TRC-649362-04-04-2016
PAYMENT DATE : 04/04/2016
PAYMENT TYPE: Credit Card
payment by phone from Chris Niehoff
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-326816 Pool Inspection Fee - Year Round $200.00
TOTAL PAYMENTS : 5200.00
III-0000204
CASE TYPE: Food & Lodging Institutions WORK CLASS: 55 - Year-Round Spa
SITE ADDRESS: 1104 CONOVER BLVD E, CONOVER NC
Applicant DEFAULT APPLICANT„
Manager HICKORY FOUNDATION YMCA. 701 1ST ST NW, HICKORY NC 28601
Manager YMCA OF CATAWBA VALLEY INC, PO BOX 280. CONOVER NC 28613
OTHER-IMPORTED ADRIAN L SHUFORD JR YMCA, PO BOX 280, CONOVER NC 28613
F:NONE NONE
OTHER-IMPORTED CHRISI'YDEAL, ,
Owner MENS YOUNG. PO BOX 280. CONOVER NC 28613
Paid By YMCA OF CATAWBA VALLEY, 1104 CONOVER BLVD E, CONOVER NC 28613
B:828-464-6130
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Sanitarian CHRISTY DEAL. .
receipt 04/04/2016 12:40 Page 1 or I