HomeMy WebLinkAboutEHPR-09-2023-45621 ENVIRONMENTAL HEALTH
Catawba County Government Center
catawba county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
public health Phone: (828) 465-8270 I Fax: (828) 465-8276
MAIIMG.LIVING.UTTER.
Email: EHAdministrativeAssistants@CatawbaCountyNC-gav
CIS aR-1)(1- )a73 -45bal
Food Establishment Walk-thru Appiicatibh
Name of Applicant: Derek Van Cleve
Contact Person: Derek Van Cleve
Mailing Address: 7662 Lakehaven Drive
City/Town: Denver State: NC Zip Code: 28037
Phone: (727) 614-1042 Fax:
E-mail Address: derekvancleveAyahoo.com
121
Location Address: .3-22 1ST Ave SW
City/Town: Hickory Zip Code: 28602
Type of Proposed Food Service:
▪Restaurant-seating ❑ Meat Market
❑Food Stand-no seating n Commissary
Was this a previous food service establishment?
❑ Yes Name if known: ❑X No
Type of water:
❑X Public Water
❑ Well
Type of Sewage:
X❑ Public Sewer
❑ On-Site Sewage System
I certify that the information in this application is correct.
Signature&Date: fi)..c.".2.fi 2 .. J n/1 '_� September 29, 2023
(Owner or Responsible Representative)
CATAWBA COUNTY
71 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
�►� PHONE:828.465.8399
C� �j�7 `� Friday, September 29,2023
4 2 5M www.catawbacountync.gov
PAYOR:
Van Cleve,Derek
PAYMENTS
TRANSACTION NUMBER: TRC-74288947-29-09-2023
PAYMENT DATE: 09/29/2023
PAYMENT TYPE: Credit Card
311380879
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
09-23-428739 110-580200-663000 Food and Lodging Review Fee S75.00
TOTAL PAYMENTS: $75.00
EHPR-09-2023-45621
CASE TYPE: Environmental Health Plan Review WORK CLASS: Other FLI
SITE ADDRESS: 724 1ST AVE SW,HICKORY NC 28602
Applicant DEREK VAN CLEVE,7662 LAKEHAVEN DR,DENVER NC 28037
C:7276141042 DEREKVANCLEVE@YAHOO.COM
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 09/29/2023 14:54 Page 1 of 1