HomeMy WebLinkAboutEHPR-04-2016-23609.TIF c ', Catawba Coun Public Health
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COIIN C1 " Environmental Health
�- . P.O. Box 389, 100-A South West Blvd., Newton, NC 28658
North Caroll�,�,` Phone (828) 465-8270. Fax (828) 465-8276
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Food Establishment Walk-tt ru pplication
Name of Applicant: �Ay \ e n P. b aV a -e r ^�yn
Contact Person:
Mailing Address: (Lk Lh /TO* (I, a (if pp - 0-0" • 4
City/Town: f,r,03 t State: n( Zip Code: a (- (10 U
Phone: Sa_ - 39,0 -I lo'7r13 Fax: n����/� - / -
E-mail Address: 11t4 _ +(,l{�tlel bd gl-t-t a) , Corn
Location Address: q I 1 S C(k-I"I e d w'��\ a . p
City/Town: I \o �/., Zip Code: x�(l5 D
Type of Proposed Food Service:
❑ Restaurant- seating (� l(t-�1l , pis
V Food Stand —no seating u,Sl n q� oil rP/1 I�JIL S 15
❑ Meat Market I n I lUkt "D hat P Cr 7 )
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Type of water:
V Public Water
❑ Well
Type of Sewage:
Public Sewer
❑ On-Site Sewage System
I certify,that the information in this application is correct.
Signature & Date: (Lt 'LI`1- d' ""' "` u . . ' , _
(Owner or Responsible Representative)
"Leading the Way to a Healthier Community"
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Health % .�m �
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�F'A \4 p CATAWBA COUNTY
\G 100,SOUTH WEST BLVD RECEIPT
�� �' NEWTON,NORTH CAROLINA 28658
rp►y+ PHONE: 828.465.8399
U ��r Friday, April 8, 2016
1842 sM1+ www.catawbacountync.gov
PAYOR:
Turner,Arlene
PAYMENTS
TRANSACTION NUMBER: TRC-651586-08-04-2016
PAYMENT DATE : 04/08/2016
PAYMENT TYPE: Cash
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-327004 EH - Walk Through/Pre-Evaluation $75.00
Fee
TOTAL PAYMENTS : $75.00
EHPR-04-2016-23609
CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI
SITE ADDRESS: 411 S CALDWELLAV, NEWTON NC 28658
Applicant ARLENETURNER, 1941 20TH AV DR NE 37, HICKORY NC 28601
C:8283206773
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 04/08/2016 10:31 Page I of 1