HomeMy WebLinkAboutAdrian L Shuford YMCA Splash Pad App 510011 04 04 16.TIF 1-LI ��-Zc C� C i
N.C.Department of Envi ronmen tat and Natural Resources
Division of Environmental Health
APPLICATION TOR.SWIMMINC POOL OPERATION PERMIT
POOL INFORMATION:
N ante of public swimming poet: Prv; U 54Nft{ )r- 64,-7710•••,'h Vcv.9
Street address of pool location: UG'1 Coo,,er Black
Coto; c ii
City: County: _�2'.- C. ¢W >4
Type gfpublicswimniing pool(checkoile) _ Swimming pool
✓, Wading pool
Spa
t_ Other (describe)
DateconstrfictedOrreniodeled:(checicone) _ BeforeMayl,1993
May 1,1993 or later
•
Dates ofoperation: opening date 41.65\\t closing date )U\i`; III.
Hours of operation: opening time `b I OO AM closing time °I tub (/A( i
OWNER INFORMATION:
Name_ofowner: uNICA 011 LcArt,c6q v./llecl
Mailing address: IS 1 5 1.1Z i 3 t Q t 1 1 5LA.;kc -2L,Z 14 tic Ivr'.( "24-ADC
Chr'1<<, Nr.ot,e t �*)247 LIUu` CtIS(.1
Contact person: Telephone:-
OPERATOR(On-Site Manager) INFORMATION:
/ rj(
Name ofpool operator: hc1> fJlrr"ocs
Address: 1 D`-1 Sev\4v,1 51 . try)tidr NC, '2.61.015 .
Telephone number: (42 i>) 57 4t' 1 le 2 Lo i
Pool operator trained by:(check one) National Swimming Pool Foundation
n (Certificate Number: t` 62 A.: &2Zb IL( I
1-7 C Oter(peasespecgj) ` Vr p4
APPLICATION SUBMITTED BY: f
Owner oroperator';C �itainr• ( �4c,c, Ai 'ehof1
Sigllahirc 7ljpedP r printed name
Date: tIiii 11
PurposeGeneral Statute 130A-282 requires the Commission Health Services toadoptrulesgoveniirig publieswimming pools.The rules in 15A
NCAC 1SA2500 require the owner or operator to apply annually for an operation permit for each public swimming pool.This form Is to allow
ownorc or operators of pubticswimming pools to apply for permits.Preparation:The information requested on this form is Lo be completed by the
poolowner or a designated representative of the owner.The completed application is submitted to the local health department tot-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
Departmentswhich are published by North Carolina Division of Historical Resources.Reorder,Additional Forms maybe ordered from:Division
of Environmental Health,Department ofEnvironmenl and Natural Resources,1630 Mail Sorvice Center,Raleigh,NC27699-1632,(Courier 52-
01-00)
DENR 3961(Revised 4/03)
Environmental Health Services Section(Review 4/06)
SBA Co CATAWBA COUNTY
ION, SOUTHWEST BLVD
INA RECEIPT
NEWTON,NORTH CAROLINA 28658
c`, to I, PHONE: 828.465.8399
vs, �C Monday, April 4, 2016
1842 SM www.catawbacountync.gov
PAYOR: YMCA of Catawba Valley
YMCA of Catawba Valley
PAYMENTS
TRANSACTION NUMBER: TRC-649364-04-04-2016
PAYMENT DATE : 04/04/2016
PAYMENT TYPE: Credit Card
payment by phone from Chris Niehoff
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-326818 Pool Inspection Fee- Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-05-2014-049840
CASE TYPE: Food&Lodging Institutions WORK CLASS: 51 - Seasonal Wading Pool
SITE ADDRESS: 1104 CONOVER BLVD E, CONOVER NC 28613
Applicant ADRIAN L SHUFORD YMCA, 1104 CONOVER BLVD EAST, CONOVER NC 28613
Owner YMCA OF CATAWBA VALLEY, 1375 LENOIR RHYNE BLVD SE SUITE 202, HICKORY NC
** NO PEOPLESOFTACCOUNTASSIGNED **
receipt 04/042016 12.41 Page 1 of 1