HomeMy WebLinkAboutNewton Recreation Pool App 500007 05 11 16.PDF N.C. Department of Environment and Natural Resources
Division of Environmental Health 4 ble 5OCCOR
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: (WY Of NEWrt7AJ /Ccent/I-n/A/ OC'T
Street address of pool location: 23 5, 3,QAOl .AVC.
City: NEWTV4 County: 0414 A'+
Type of public swimming pool: (check one) LEI Swimming pool
❑ Wading pool
❑ Spa
n Other (describe)
•
Date constructed or remodeled: (check one) n Before May 1, 1993
n May 1, 1993 or later
Dates of operation: opening date (Malt /0( 7-0(1 closing date Alt/..51— z 7/ zo d
Hours of operation: opening time /012 closing time 6-C7 O p r„
OWNER INFORMATION
Name of owner: at-V OF 46WMI\J
Mailing address: Po 6cX $3 p
Contact person: Cfl%'�7L A. 'rte L Telephone: 6 06 P/l S - `f'3 17
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: ( fYL A- 9Cr Les-
Address: �Z 3 $+ OP-40y A
rJ n/
Telephone Number: Z( 7 -¢4oS"
/po boil-50 70
Pool operator trained by: (check one) National Swimming Pool Foundation
(Certificate Number: CA! 'LE
❑ Other (please specify) YMCA
APPLICATION SUBMIT II D B
Owner or operator: /" ,� Cr1/ZOL tQ r 51-/L S
Signature Typed or printed name
Date: Me( // / ��
Purpose:General Statute 130A-282 requires the Commission for health Services to adopt rules governing public swimming pools. The rules in I5A
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 the 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)
y'A CATAWBA COUNTY
�Ci 100A SOUTHWEST BLVD
C t H
NEWTON,NORTH CAROLINA 28658 RECEIPT
sa__ , PHONE: 828.465.8399
V va�oJ C Wednesday, May 11, 2016
/842 9,1 www.catawbacountync.gov
PAYOR:
CITY OF NEWTON,
PAYMENTS
TRANSACTION NUMBER: TRC-670845-11-05-2016
PAYMENT DATE : 05/11/2016
PAYMENT TYPE: Check 55117
INVOICE NUMBER FEE NAME FEE AMOUNT
05-15-317574 Pool Inspection Fee - Seasonal $50.00
16"328239 MR 1IIii{lire,: ?f; rial1, Pool�ilnspectlon lF4ee'SeaSonalEPOttlI. "; S1001
TOTAL PAYMENTS : 5150.00
FLI-0000067
CASE TYPE: Food&Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 23 S BRADY AV,NEWTON NC 28658-
Manager CITY OF NEWTON, PO BOX 550, NEWTON NC 28658
** NO PEOPLESOFT ACCOUNT ASSIGNED **
OTHER-IMPORTED NEWTON RECREATION DEPARTMENT, PO BOX 550,NEWTON NC 28658
F:NONE NONE
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