HomeMy WebLinkAboutNewton Elks Wading Pool App 510000 05 19 16.PDF N.C. Department of Environmental and Natural Resources I
Division of Environmental Health -i 1-ZoIbS I
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: P.-J L.
Street address of pool location: q2-1q e..2C10.tC/nr;v
City: County:
Type of public swimming pool (check one) ❑ Swimming pool
• Wading pool
❑ Spa
❑ Other(describe)
Date constructed or remodeled: (check one) Before May I, 1993
❑ May 1, 1993 or later
Dates of operation: opening date l 1 1e,„ 0? closing date C� 5
Hours of operation: opening time C\ (}w-" closing time 9p
OWNER INFORMATION:((� `
Name of owner: 1` Q.. , 1kS Ln p /
Mailing address: P0• �)1OX 4O , K`Q.„ n , 1\\l 3wb 9
Contact person: le\\ e l r_\\Jrcr, Telephone: Spy} PIbD-q85
OPERATOR(On-Site Manager)I FORMATION: ` p
Name of pool operator: JCn,e_ '' \\ CG-\\\C -/ 1
Address: LC °) W f Sk- �S4- S3rf -F i- / t,e j- n , r iLSc
Telephone number: not cf o
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:
Other(please specify) hq A .t'„ -1 C- / 17 4 /U'/t'
APPLICATION SUBMITT I B. • / (f 5--r�z.sk
Owner or operator: -//t // /Cie /l e Cc I1 r Ilcn
• ature Typed or printed name
Date:
Purpose General Statute I 30A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in 15A
NCAC 111A.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!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)
4'A CATAWBA COUNTY
O-k IOOA SOUTHWEST BLVD
FT M NEWTON,NORTH CAROLINA 28658 RECEIPT
kick! PHONE: 828.465.8399
U c l it.. 'C Thursday, May 19, 2016
is 4'1 sM www.catawbacountync.gov
PAYOR:
NEWTON ELKS LODGE,
PAYMENTS
TRANSACTION NUMBER: TRC-675528-19-05-2016
PAYMENT DATE : 05/19/2016
PAYMENT TYPE: Check 1180
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328538 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000174
CASE TYPE: Food& Lodging Institutions WORK CLASS: 51 - Seasonal Wading Pool
SITE ADDRESS: 625 WEST RIDGE DR,NEWTON NC
Manager NEWTON ELKS LODGE, PO BOX 402,NEWTON NC 28658
OTHER-IMPORTED NEWTON ELKS LODGE WADING 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 13:01 Page 1 or 1