HomeMy WebLinkAboutNewton Elks Lodge Swim Pool 500071 05 19 16.PDF N.C. Department of Environmental and Natural Resources
Division of Environmental Health J7c5scuo V1
APPLICATION FOR SWIMMING POOL OPERATION PERMIT •
POOL INFORMATION:
i
Name of public swimming pool: MP, a t Y--)
Street address of pool location: �� i)( , �(e
City: County: P n �C �.� ��0.
Type of public swimming pool (check one) -S Swimming pool
❑ Wading pool
❑ Spa
❑ Other(describe)
Date constructed or remodeled: (check one) 'W Before May 1, 1993
❑ May I, 1993 or later
Dates of operation: opening date (t( a� closing date 5 1 l�� 5
Hours of operation: opening time —[ (A v--. closing time 01 p �1
OWNER INFORMATION: 1
Name of owner: (KUL,;2u n I1 L S �rtd ,C_
Mailing address: P o X k L-t()a , M 2 n ,
Contact person: e\\2 LU .k Telephone: -1 o 4 - go,Q -q s/ 9
OPERATOR (On-Site Manager) FORMATION: I
Name of pool operator: �(t-rt )e 1 1('JLGfl
Address: (, 3°1 /A )e S 1- /5* P?_. E ,,tnn, Kt( 50
Telephone number: 1 64 A U 9 -
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:
Other(please specifj) CU(t C— C I n,�
APPLICATION SUB tIITTED BY• 1 j7 /c
Owner or operator'a� , 4$ /// �� Q, (IL C( .i/(_1erN
Ignature Typed or printed name
Date: 9 '/g / Co
Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in ISA
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 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 I listorical 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)
d,t1;) • Cp CATAWBA COUNTY
100A SOUTHWEST BLVD
f 't NEWTON, NORTH CAROLINA 28658 RECEIPT
a ? PHONE: 828.465.8399
U `�11"� vasvr k'C Thursday, May 19, 2016
/842 sm www.catawbacountync.gov
PAYOR: NEWTON ELKS LODGE
NEWTON ELKS LODGE
PAYMENTS
TRANSACTION NUMBER: TRC-675527-19-05-2016
PAYMENT DATE : 05/19/2016
PAYMENT TYPE: Check 1180
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328537 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : 5150.00
FLI-0000071
CASE TYPE: Food & Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 625 W J ST, NEWTON NC
Manager NEWTON ELKS LODGE, PO BOX 402, NEWTON NC 28658
** NO PEOPLESOFT ACCOUNT ASSIGNED **
OTHER-IMPORTED NEWTON ELKS LODGE SWIMMING POOL, PO BOX 402,NEWTON NC 28658
F:NONE NONE
Pool Operator JONELLE CALLAHAN, 639 W 1ST ST, NEWTON NC 28658
B:7049029859
receipt 05/19/2016 13:00 Page 1 of 1