HomeMy WebLinkAboutNewton Elks Lodge Swim Pool PERMIT 500017 05 25 17N.C. Department ofEwimsemat and Natural Resources
D'nis w ofEmirovmenml anith
PUBLIC SWIMMING POOL
OPERATION PERMIT
Time In: 0 2: 0 2 Dam Tine Out: 3: 2 5 ®Pm
Total Tine: t hr 23 minutes
Permission is granted to:
M I C H E L L E G I B S 0 N
'Update Existing Facility?
NmFacilitym: 2 0 1 8 5 0 0.0. 1 7
Old Facility m:
*Date Issued 0 5 / a 5 / a 0 1 7
'Status Code: I
Owner or Operator of
N E W T O N E L K S L 0 D G E S W I M P 0 0 L
Name of Public Swimming Pool
to operate a public swimming pool as defined in G.S. 130A-280 and 15A NCAC 18A.2500 at
Address 6 2 5 W T S T
city N E W T O N ST N C zip 2 8 6 5 8
County 1 8
Type ofPool: (check one)BSwimmingPool -Seasonal BSwimmingPool-Year Round
Wading Pool - Seasonal Wading Pool -Year Round
HSpa - Seasonal 2 Spa - Year Round
Specialized - Seasonal Specialized - Year Round
Water Supply: 5s- Municipal/Community
Territory #: 01
Waste Water .System: 3-3-Municipal/Community
EHS: 2031 - Levin, Paige Signed12
Agent
N.C. Depmmte fEavlro n[ dNmualR o rots
DivisenofEvvsmvmevtal ealih
-Expiration Date: 1 0 / 3 1 / 2 0 1 7
Remarks
4000
r�
G
N.C. Department ofEnnronmem and'Natural Resources 2018500017
Division ofEnvimnmental Health IdentificationNtmber
05/25/2017
PUBLIC SWIMMING POOL Datefssmd
OPERATION PERMIT Status Code:
Permission is granted to MICHELLE GIBSON of NEWTON ELKS LODGE SWIM POOL
Owner or Operator Name ofPnblic SeimmingPool
to operate a public swimming pool as defined in G.S. 130A-280 and 15A NCAC 18A .2500 at
625 W J ST, NEWTON, NC 28658
SreetAd*e&; of Pod Locafon
18
Comtry
Type of Pool: (check one) Swimming Pool
Wading pool
Spa
Specialized
Other (describe)
Signed:o^ h,r _ Agent
Dmsta .fE ofEnnr lthfttNa mmol
Division ofEmimmnm ea1N
Expiration nate: 10/31/2017
Remarks:
INSTRUMONS
Purpose: General Statute 130A-281 states'No public swimming pool maybe opmedfor use unless the owner or operator has obtained
an operation permit issuedby the Depmmmt'. General Statute 130A-282 requires the Commissiw for Health Services to
adopt rules induding requiremmu fa aprplica6w review, expiration, imewal, mdrevocatim a smpmsim of aro operating
permit Those mics are cmtained in 15A NCAC l8A .2500.
This form is to be used as the permit specified above.
preparation: Local mvirmmmtal health specialists shall issue apemit every time anew or reissued permit is indicated prepare an
original and me copy fm
1. Original given to pool owns or operator.
2. Copy for the local health department.
In the event thepamit/translhmal permit is suspended orre eked, complete the Suspenssm/Revoation form (DEM
4009B).
Disposition: Thisfmn may be destroyed in acmr&oce with Standard 8.11.6., Inspection Records, of die Records Disposition Schedule
published by d.e N.C. Division ofArchives and History.
Additional forms may be ordered from Division ofEnvironmantal Health
1632 Mail Service Center
Raleigh, NC 27699-1632
(Carrier 52-01-00)
EHS 3962 (Revised 7/05)
Environmental Health Services Section (Review 7/08)