HomeMy WebLinkAboutHickory Trace East App 500090 05 06 16.TIF piIr r n r mm m7 Tm+f ."""nt5eaH ,
I 11 ),..I I 0>li+)�[I-Ildl">TIdV d l"'':il+t�f 9 I �,a,!t 111111 xt('.. `' ",� ,I1 11IhL,$Mr i N!n 'll+i !i. �+I ! 'R 'i, 1 01• �Ia t 1 I„ 1. , .. 1 li• 111,•,. 1! t!•,d•l l� ti 1 hiI ,'I +f,•I 1 i i.�f 11 ��: h , ' i' .. " !I I +I i d:ii 'ii,.�' i.iii I+1,a Lr•r! ii,,,iiii it
1 II 1 V"' I�� ,II. ill
it i I' 1• ! ti .
•
N.C. Department of Environmental and Natural,Resources
• Division of Environmental Health I, (O 0
. I 11 li.e;
APPLI'CATION FORSWIMMING:POOL OPERATION PERMIT
• POOL-INFORMATION: +I
ii1
Name of public;swirnmingpool: , f4(CKA(7 Troup ('),'llac,:i-- F O4f
Street address of pool location: I ) GO `Jtll St PE' • •
City: County: flICKnr' l afar hey .. .
Type of public swimming pool(check one) Swimming pool •
o Wading.pool.
1
o Spa
' 0 Oilier(describe) -
a
Date constructed onremodeled:(check one) IB Before May 1, 1993
o May 1, 1993,or,later
•
Dates of operation: opening date! /Voy :!A'
a'5- /6 closing date '/0 /5 �6“i
y i FLr;.
Hours of operation: opening time 'g:60.p1)1 closing time 4 :60PPk.:
' OWNER INFORMATION: ,
. J
Name of owner: P✓ncessronaT `Ret/lp...'4iiuy,.,+r,hl..7e..... • - -
Mailing address: ,Po. 86)4 70' 5, ,'1a A/C P-7675 .
/ I°: 4'1,1.;
Contact person:; (o6'ry Ye i/on1 chi`. . Telephone: 72 8 ..328 55GO
•
OPERATOR(On=Site Manager)'INFORMATION: I.
Name of.pool:operator: -Gar/ rig fIoh. 'Sr'- - . •
Address: ;2:2.0, I ne till 7}1, L e1 P . l cy/Orrv//hi .4 'C-• 2818/ '
Telephone,number: 1'14 Act f-7 3 6'1i' .
Pool operator trained by::(check one) 0 National Swimming Pool Foundation'
' - (Certificate Number: . , 'l).
t Other(please spec):flarerihn i tpinnl hw/FIS1, ,'%re': 1
APPLICATION SUBMFTTEDIB,Y: .
'
Owner or'operator A,/ 9 > 6rtr /4/1” 7fr'a
Sigma e r Typed or printed name
pDate
Purpose General Statute 130A-282 requires the Commission Health Sereiceslto,adopt rules1govemmg public sNlmmmg pools11The`mles in 15A
NCAC I SA.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 per/nits:Preparation:in.&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 deparunent for the county'.in
which the public swimming pool is located.A separate application must be'completed for each public swirnmmg pools Copies,Original to'be
li i maintained at the local health.department:Disposition Pteasf•refur,to Records R etentioniandiDisposnlon,Schedule for,County/District Health.
Deparbnent,which are published by North Carolina Division of Elisiorica'Resources Reorder Additional Fortes may be ordered from'Division .
of Environmental Health;Department of Environnxnt and Natural;Resouries`1630 Mail Service Center,Raleigh,NC 27699-1632 (Courier'52-
01-00). I „,•1
DENR 3961(Revised 4/03) ;
Environmental Health Services Section(Review 4/06) -
r
IllalalU I ,
i
, Il)I l II lI ,1��h>,
`1111!!14! hildi(�,aillh +
111 1 t ; il'ilp, '
h it l r >ra,.,.,
tit
fli
4 ,.r
....1,.„.. - ..1 -_.. 11.`.Il+i.iil�' ..:.:.,,.: :,. „rc, n., 0_. . t 1... .._.� ...-
CATAWBA COUNTY
:;y(� IOOA SOUTHWEST BLVD
Y NEWTON,NORTH CAROLINA 28658 RECEIPT
hs�Pi'; PHONE: 828.465.8399
"Akira o°' Friday, May 6, 2016
/842 sm www.catawbacountync.gov
PAYOR: HICKORY TRACE VILLAGE
HICKORY TRACE VILLAGE
PAYMENTS
TRANSACTION NUMBER: TRC-668077-06-05-2016
PAYMENT DATE : 05/06/2016
PAYMENT TYPE: Check 009681
Received in Hickory
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328102 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000173
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 1260 5TI-I ST NE AV, HICKORY NC
Establishment HICKORY TRACE EAST, 1250 5TH ST NE, HICKORY NC 28601
F:NONE NONE
Manager HICKORY TRACE VILLAGE, 1250 5TH ST NE, HICKORY NC 28601
** NO 13 EOPLESOFT ACCOUNT ASSIGNED **
Pool Operator PROFESSIONAL REALTY MGM'I' INC, PO BOX 70, SPARTA NC 28675
C:8282917364
receipt 05/06/2016 14:59 Page 1 of 1