HomeMy WebLinkAboutAbingdon Glen Village App 500088 04 14 16.TIF N.C. Department of Environmental and Natural Resources 4 ZO I13 _"`J
Division of Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: / / 1t
Name of public swimming pool: � /y)C( �;(/J/t G/e/'1 /i %//a cy p
J a of
Street address of pool location: `� /> / „2 009/1e.. Ali
City: County: ICJ/4/)1,�—�// i /C.- 2$ Intl/ A /CILL
Type of public swimming pool(check one) 11d Swimming pool
❑ Wading pool
❑ Spa
•
❑ Other(describe)
Date constructed or remodeled: (check one) Cl Before May 1, 1993
May I, 1993 or later
/
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Dates of operation: opening date -'f— J closing date io'I' /4
Hours of operation: opening time ,' / //4 closing time 9/W7)/-////
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OWNER INFORMATION: J / / 6' J
Name of owner: )9 Ain nib A Pell ///7/CLP �5S6C/O, //iAl / ljc,
Mailing address: (`5- 0/ _201;/ bt qGt r 4/ f/JGI�pm y At 2o I
Contact person: �J411,12>a Ae PAPMI / �y
OPERATOR(On-Site Manager)INFORMATION:
Name of pool operator: , )c liuForD e nG ity aNt / ly
Address: 5/2/ 24-7)-11 ire A / g/GK(Py Al G 2S-106
Telephone number: Q`Z 8- c2 11p 7 6 69 z-
Pool operator trained by: (check one) l2" National Swimming Pool Foundation
(Certificate Number:
❑ Other(p l e a s e s p e c i f y) /j'v i 0,11 _Sk ICY L k fq'/uutr\
APPLICATION SUBMIT ED B •
Owner or operator: v �t' /w _ Sh ij' 'n/l e-rn e, y/
1/
tgna re Typed printed name -
Date: /fl/), 0
Purpose General Statute I30A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in ISA
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 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)
4'A CATAWBA COUNTY
OG IOOA SOUTHWEST BLVD
�� :� V NEWTON,NORTH CAROLINA 28658 RECEIPT
�'Q' �e1Pe = PHONE: 828.465.8399
V A Thursday, April 14, 2016
\842 sm www.catawbacountync.gov
PAYOR:
ABINGDON GLEN HOMEOWNERS ASSOC INC,
PAYMENTS
TRANSACTION NUMBER: TRC-655285-14-04-2016
PAYMENT DATE : 04/14/2016
PAYMENT TYPE: Check 4886
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-327232 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : S150.00
FLI-0000171
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 501 26TH AV NE, HICKORY NC
Manager ABINGDON GLEN HOMEOWNERS ASSOC INC, 501 26TH AV NE, HICKORY NC 28601
OTHER-IMPORTED ABINGDON GLEN VILLAGE, 501 26TH AV NE, HICKORY NC 28601
F:NONE NONE
Pool Operator SHUFORD ABERNETHY, 501 26TH AV NE, HICKORY NC 28601-
C:(828)381-2978
receipt 04/14/2016 14:36 I'age 1 of 1