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N.C.Department of Environmental and Natural Resources 53 I_
Division of Environmental Health ID D g01$53 61)1R6
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: _ It n
Name of public swimming pool: I N, LC. fld J 4
Street address of pool location:
205\ Asi- �, car
City: County:tY \iI C (OP*IN 1
Type of public swimming pool(check one) Swimming pool
❑ Wading pool
❑ Spa
❑ Other(describe)
Date constructed or remodeled: (check one) ❑ Before May 1, 1993
111/.7
ay 1, 1993 or later
Dates of operation: opening date War r JY1( closing date
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Hours of operation: opening time 10•A 0() a p closing time !0,V d,}2�1
OWNER INFORMATION:
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Name of owner: 1 1 t • d • 42 A IP m /,..,
Mailing address: M\ _ `' tll' •• , - pp t\1 C S �Qb 2_
Contact person: Arm 0,91 A 4 I i t,N) Telephone: ' 2g- c9- c
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OPERATOR(On-Site Manager)INFORMATI. 1:
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Name of pool operator: --} �- Y ,�� ��
Address: 210\ , St SA GG 1(il-�Y� 1 N4C. r L-0(�f
ill
Telephone number: I y-3-o-\ OD \
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Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number: ( 3'* (-0 31-O is )
W Other(please spec) lay , . ' t f A Is
APPLICATION SU: ' - ' < a
Owner or opera .r: ..
it, ,' 1 nrRicted name
Date: 1
Purpose General Statute I30A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in 15A
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 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-
Ol-00)
DENR 3961(Revised 4/03)
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Environmental Health Services Section(Review 4/06)
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4,A co CATAWBA COUNTY
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'' P•, 100A SOUTHWEST BLVD
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F'' NEWTON,NORTH CAROLINA 28658 RECEIPT
., ' �® PHONE: 828.465.8399
U\ 4 i 711 Wednesday, August 24, 2016
1842 sM www.catawbacountync.gov
PAYOR: Summit Management Services
Summit Management Services
PAYMENTS
TRANSACTION NUMBER: TRC-798991-24-08-2016
PAYMENT DATE : 08/24/2016
PAYMENT TYPE: Check 9214
received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
08-16-331986 Pool Inspection Fee-Year Round $200.00
TOTAL PAYMENTS : $200.00
FLI-0000192
CASE TYPE: Food& Lodging Institutions WORK CLASS: 53 -Year-Round Swimming Po.
SITE ADDRESS: 2051 21ST ST SE DR, HICKORY NC
Establishment THE LEGENDS 1,2101 21ST SE, HICKORY NC 28602
F:NONE NONE
Paid By SUMMIT MANAGEMENT SERVICES, 730 W MARKET ST,AKRON OH 44303
B:3306332272
**NO PEOPLESOFTACCOUNTASSIGNED **
receipt 08/24/2016 16:06 Page 1 of 1