HomeMy WebLinkAboutConover Swim Club App 500021 05 09 16.TIF FCC ' °��
N.C. Department of Environmental and Natural Resources I` ��, C
Division of Environmental Health
r APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: //
Name of public swimming pool: ja(101./er. St t�t N'+ �t � d/UI�
Street address of pool location: a/ � /lye A/C.
City: County: OAJO U Zr P✓�lv}wft✓4
Type of public swimming pool (check one) Swimming pool
❑ Wading pool
❑ Spa
❑ Other(describe)
Date constructed or remodeled: (check one) lW.-- Before May 1, 1993
❑ May 1, 1993 or later
Dates of operation: opening date 51 ao - /6 closing date 9- iv /60
Hours of operation: opening time _ /0 closing time 9
OWNER INFORMATION:
Name of owner: COX-17/e_, sr St"-, r ,ti. t .--c, ` / D /ti C°•
Mailing address: /J o /3D)( / 74I (04 0vcr ,cis - 6/3
Contact person: N�(te(o¢� (9,8ocJL Telephone( S ) 3/0-- /615 6
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: 11 Z,¢avir4 i ff./re j 1ek
Address: 020 5 /4 3rd /fie &<,m c- Ade ?'6/3
Telephone number: Cass') �70) f.30
Pool operator trained by: (check one) National Swimming Pool Foundation
(Certificate Number: 0 9f 3 0/3 '63 1
❑ Other(please specify)
APPLICATION SUBM :
Owner or operator: / — • v° ei i I, rAy,4
Signature Typed or pri ted ame
Date: 5- 97/6 -
Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in I5A
NCAC 18A2500 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 insist 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 Itistorical 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)
ySy'A p CATAWBA COUNTY
IOOA SOUTHWEST BLVD
� ��� � NEWTON,NORTH CAROLINA 28658 RECEIPT
nmmrs r"-..l) "-I
vaV*� PHONE: 828.465.8399
U `* ,r in Monday, May 9, 2016
/842 SM www.catawbacountync.gov
PAYOR:
CONOVER SWIMMING CLUB INC,
PAYMENTS
TRANSACTION NUMBER: TRC-6 693 99-09-05-20 1 6
PAYMENT DATE : 05/09/2016
PAYMENT TYPE: Check 1652
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328122 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000076
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 221 5TH AV NE CIR, CONOVER NC
Manager CONOVER SWIMMING CLUB INC, PO BOX 274, CONOVER NC 28613
** NO PEOPLESOFT ACCOUNT ASSIGNED **
OTHER-IMPORTED CONOVER SWIM CLUB MAIN POOL, PO BOX 274, CONOVER NC 28613
F:NONE NONE
Pool Operator MICHAEL O'BOYLE, 704 2ND AV PL NE, CONOVER NC 28613
C:8283101606
receipt 05/09/2016 09:40 Page I of I