HomeMy WebLinkAboutWestminister Park App 500023 07 21 16.TIF •Ir
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tr., ,C,4�.Qtj?,4 N.C.Department of Environ mental and Natural Rso
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Division ofEnvironmentalHealth Ft / . GI dalO79
APPLICATION FOR SWIMMING POOL OPERATION P ' MIT
POOL INFORMATION: I D DDI<6,510003
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Nameofpublicswimmingpool: t 4 , : ' -/ a
- a
Street address of pool location: O. 'r ' e
a r
City: County: I. • /I i9ei. /:
Type of public swimming pool (check one) : Swimming pool
Wading pool
• Spa
U •ther(describe)
Date constructed or remodeled:(check one) Pe Before Mayl, 1993
1//jUMay 1, 1993 or later q /
Dates of operation: opening date ______ �-`_`__ 0closing date /' �/�
Hours of operation: opening time 8at29.1 closing time 9 flj
OWNER INFORMATION: //k7 r 1 /1
Name of owner: // /�/ f(�Y'/
Mailing address: l2' X �(�
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Contact person: __ Telephone; � 4
L%YY;
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: L.,; /il-E Ai5
Address: 4 r— e< . �N �1�51 X �- if ' ,
Telephone number: c. �2 9e .5" -/ i, -7).C,
Pool operator trained by:(cheek one) n National Swimming Pool Foundation /�"'�
n (Certificate Number: 1
nOther(please specify)
:,' ' (CATION SUBMIT .D BY:
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Owne or operator: /�! !/ : .i!% , Ai 2e. .a
Signature Typed or printe n me F
Date: 2720,-/A
Purpose General Statute 130A-262 requires the Commission Health Services to adopt rules governing public swimming pools,The rules in 15A
NCAC 15A.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
wnlcn me public ewimminp 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 Historical Resources.Reorder Additional Forms maybe ordered from:Division
of Environmental Health.Department of Environment and Natural Resources.1830 Mail Service Center.Raleigh.NC 27099-1632.(Couder52-
01-00)
OENR 3961(Revised 4/03)
Environmental Health Services Section(Review 4/06)
�'A CATAWBA COUNTY
!r IOOA SOUTHWEST BLVD
!'r+t 2 NEWTON, NORTH CAROLINA 28658 RECEIPT
\ict 4,--.1l"vQetciiiH PHONE: 828.465.8399
CJ jkkvdy Thursday, July 21, 2016
/84www.catawbacountync.gov
PAYOR:
WESTMINISTER PARK HOA,
PAYMENTS
TRANSACTION NUMBER: TRC-744451-21-07-2016
PAYMENT DATE : 07/21/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
07-16-330760 Pool Inspection Fee - Seasonal 5150.00
TOTAL PAYMENTS : S150.00
FLI-0000079
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool
SITE ADDRESS: 2705 N CENTER ST, HICKORY NC
Manager WESTMINISTER PARK HOA. 2705 N CENTER ST, HICKORY NC 28601
** NO PEOPLESOFTACCOUNT ASSIGNED **
OTHER-IMPORTED WESTMINISTER PARK 1-I0A, 2705 N CENTER ST#00, HICKORY NC 28601
F:NONE NONE
Pool Operator SUNSHINE POOLS LLC, 2773 N CENTER ST, HICKORY NC 28601
B:8283227665 SUNSHINEPOOLS@CHARTERINTERNET.COM
receipt 07/21/2016 14:14 Page 1 o(1