HomeMy WebLinkAboutLake Hickory Country Club PERMIT 500022 05 16 17.LS.PDFN.C. Dep arunmt of E w ironmmt and Natural Resources
Oh -Won offmirowumtal Health
PUBLIC SWIMMING POOL
OPERATION PERMIT
Time In: 0 2' 4 0 0F!j am Time Out: 3' 0 B 0"
Total Time: 28 minutes
Permission is granted to:
*Update Existing Facility?
New Facility M. a 0 1 S 5 0 0 0 a 2
01dFacility ID:
*Date Issued 0 5/ 1 6/ d 0 1 7
Status Code: i
L A K E H I C K O R Y C O U N T R Y C L U B
0 iv ner or Operator of
L A K E H I C K O R Y C O U N T R Y C L U B
i J i
Name of Public Swimming Pool
to operate a public swimming pool as defined in G.S. 130A-280 and 15A N- CAC 18A .2500 at
Address 4 3 0 1 T H A V N W
City H I C K O R Y S T N C zip x 8 6 0 1
County 1 8
Type of Pool- (check one) Swimming Pool -Seasonal ❑Swimming Pool- Year Round
❑Wading Pool - seasonal ❑Wading Pool -Year Round
❑Spa - Seasonal ❑Spa -Year Round
F1 Specialized - Seasonal ❑Specialized - Year Round
Water Supply.
l 5-5-Municipal/Community
Territory #: 01
ENS: 1856 - sears, Luke
*Expiration Dare: 1 0
Remarks
Signed
V.C. Department
Divisim of Envb
1 1 5 1 0 0 1 7 6
Waste Water System:
Mand`
Health
3-3 - MunicipallCcmmunhy
Agent
Crrracars l
RP"jXing
4000
hi.C. Department ofEn-L ironrr:ent and Natural Resources
Division of E nvi rorunental Health
I it" 0 0 IMMIN 1kVj 101 WIN Zell] I
OPERATION PERMIT
Permission is granted to LAKE HICKORY COUNTRY CLUB
Owner or Operator
2018500022
Identification dumber
05/16/2017
Date Issued
Status Code:
of LAKE HICKORY COUNTRY CLUB
Xame of Public .5wimmingPool
to operate a pi lbIje swimmino- pool as defined in G.S. 13 OA -290 and 15A NCAC 18A .2500 at
430 17TH AV NW, HICKORY, NC 28601
StrmrAd&-ess ofPool Locsuion
18
cQtity
Type of Pool: (check one) !❑ Swimming Pool
Wading pool
Spa
Specialized
Other (describe)
Expiration Date:
Remarks
10/16/2017
Signed: Agent
N.C. Department of ent an _ "atur sources
Di-Ysion ofEn�i tel Health
tk ': tl + ►b
f
Purpose: General Statute 13OA-281 states "No public swimming pool maybe opened for use unless the owner or operator has obtained
an operation permit issued by the Department" . General Statute 130A-282 requires the Compri scion far Health Services to
adopt ntles including requirements far application review, expiration, renewal, andrevocation or suspension of an operating
permit_ Those rules are contained in 15A NCAC 18A _2500_
Thisfarm is to be used as the permit spmified aWye.
Preparation: Local environmental health specialists shall issue a permit every time anew or reissued permit is indicated. Prepare an
original and one copy for.
1. original given to pool owner or operator.
2_ Copy for the local health department_
In the event the permit(transhional pemut is suspended or revoked, complete the Suspension'Revocation form (I)E"NR
4009B).
Disposition: This farm maybe destroyed in accordance with Standard 8.$.6., Inspection Records, of the Records Disposition Sa§edule
published by the N.C. Division of Archives and Hi story.
Additional forms may be orderedfrom: Division of Environmental Health
1632 Mail Service Center
Ral ei gh. NC 27699-1632
(Courier 52-01-00)
EHS 3962 (Revised 7/DS)
Environmental Health Services Section (Review 7168)