HomeMy WebLinkAboutHickory Trace West App 500091 05 06 16.TIF „,,,t.,;n, li I 3 ii ',7 7 r9 iraa 'M'1'1 717. , ,T;7f7 9'� ryt tR m ^�i,tip."., f 19f, R 1 v R Int '
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N.C. Departmlent of Environmental'and.Natural Resources
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Division of Environmental.Health .
APPLICATION.FOR SWIMMING POOL OPERATIONfPER_MIT
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POOLINF,ORMATION: li •
Name of publicswimmingpool: /4lcknrr JTvoce (lt`I/api '/sf I.
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Street address of pool.location: ./2,,9” sfh 5 h •
City: County: I .MICA ory 4 r� Q
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Type of pubhoswimming pool (check one) ❑ Swimming pool
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O Wading pool
❑ Spa
❑ Other(describe)
Date constructed or renlodeledi(check One) gEl"---- Before May l;1993
I. - May 1, 1993 or later
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Dates of operation: opening date Si-2.S-/6 closing date /0-/5' /G':,
Hours of operation: opening time `C:00 JIM/P1 closing time .9:60I/2/1/:::
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OWNERWI■FORMATION
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i - Name of owner. •PYOTr S'SinaaJ kealy %4hm 911-;ZItc-.•• - - '1.4
Mailing address: Pr]' Qof 7ei ' Spa..Ia 4''.C• • .286r75 1
Contactperson:` f&ry ii)bi.-T-: Telephone: F.2R=:32b'-S56:0
;OPERATOW(Oin-Site N Manager)INFORMATIO/N:�
ame of pool operator: • Cary e•11'o r ITY'. •Address: .2201 ,ae..0I Tra'k: Rd. tit In•esv,/le.r4/ C 2&LA/
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Telephone number: 1J2 g >-0/-736V
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Pool operator trained by: (check one) ❑ . National Swimming,PoolIFoundation; •
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(Certificate Number: ..., ) . . F
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APPLICATIS
ON, UBMI7TED''BY/: t
Owner or oPerator: :. 112 4— { Ga /4n Ti-`•Signa -,. * Typed oprinted name l, + " . 1
• Date:
Purpose General Statute 130A-282 requires the Commtss,ohHealth Services lo adopt ruler,governing public swimming pools The miles tn•I SA;,.
NCAC 18A: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 publicswnmming pools to apply for permus'Prepamtioy The information requested on tha(orm Is to be completed,tiy the:
' pool owner or a designated representative of,the owner'The completed'application is submitted to the local;health deparmsent for tht county,n'^ -
which the public swimming pool is located"A-separate application must be completed Inr'eaCht public swimming pool Copies Original,10 be;' .
maintained at.thwIden•healh department..Disposition: Please refer to Records Retention and Disposition Schedule`for County/Drsmct Health
Departments which are published by North Carolina Division of Historical Resources Reorder.'Addition'al'.Pones may be ordered fmm.Division•
of Environmental Hcalth;IDepartment of Environment and-Natural Resources,:1630 Mail Service Center,Raleigh,NC,27699 71632,(Courier 52••
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DENR 3961(Revised 4/03)
Environmental Iealtli Services Section(Review 4/06) ,
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rik Cp CATAWBA COUNTY
7,:74 Ai I IA IO0A SOUTHWEST'BLVD
NEWTON, NORTH CAROLINA 28658 RECEIPT
ps��� a PHONE: 828.465.8399
®�w. '`C Friday, May 6, 2016
\$42 SM www.catawbacountync.gov
PAYOR: HICKORY TRACE VILLAGE
HICKORY TRACE VILLAGE
PAYMENTS
TRANSACTION NUMBER: TRC-668111-06-05-2016
PAYMENT DATE : 05/06/2016
PAYMENT TYPE: Check 009682
Received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328107 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000440
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool
SITE ADDRESS. 1209 5TH ST NE,HICKORY NC
Establishment HICKORY TRACE WEST, 1250 5TH ST NE, HICKORY NC 28601
F:NONE NONE
Manager HICKORY TRACE VILLAGE, 1250 5TH ST NE, HICKORY NC 28601
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Pool Operator PROFESSIONAL REALTY MGMT INC, PO BOX 70, SPARTA NC 28675
C:8282917364
receipt 05/06/2016 15:15 Page T of I