HomeMy WebLinkAboutLa Quinta Spa App 520007 03 25 11.tif s ��.
N.C. Department of Environment and Natural Resources
Division of Environmental Health � ��rcl���
0
APPLICATION FOR PUBLIC SWINIMING POOL OPERATIO PERMIT
POOL INFORMATION: rL �� 3_ ��_ � j,p,� 4�'�
C�t,U r�� � _Si,��e� �
Name of public swimming pool: ��1 1 =n n
Street address of pool location: �� 0� � I�Gt-+ ► -c=� r�`L' L� �u.( Yc� �C�
.
City: � C�rt�?1/ �Y' County: �c�.�c�-i,l; � G
Type of public swimming pool: (check one) ❑ Swunming pool
❑ Wading pool
� Spa
❑ Other (describe)
Date constructed or remodeled: (check one) ❑ Before May 1, 1993
❑ May 1, 1993 or later
Dates of operation: opening date � y f i i closing date I� �� ��
Hours of operation: opening time � 0 P�m closing time l 1�cn
OWNER INFORMATION �
Name of owner: �� �o �c�� ��i�t+�t�i�1 � ZL� Lc� �,.iU r�u Ti,n � S�
Mailing address: ��oC�� ,�CU1 C:�r��. Rc� ,�C-�c'V�'Y. NC ; 2�'61 �
Contact person: Ke.vc�:,� �c�,��� Telephone: � 2� - ���i �" ��� 5
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: -J G�-K �c�rn�'i � � C k —
Address: �( 0�7 , ( �i `.,rcw'C C�v..yv��, I�c� , ���L���, /�/� . 2 `�E ! 3
Telephone Number: �'2 � � S I( � C7
Pool operator trained by: (check one) '� National Swimming Pool Foundation
��}r��� cnv� S'�%+ r�1mi��y P� � (Certificate Number: 0`3�-S I I' �� )
�, sp��i A�S�=����fi�'�'� ) � Other (pleasespecify)
APPLICATION SUBMITTED : � �
Owner or operator: ���"' ���� KE v.�}� PP+TEL _
Sig� re Typed or printed name
Date : � 2 S" i (
- � -
Purpose: General Statute 130A-282 requ'ves the Commission for Health Services to adopt rules goveming 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 appty for permits. Preparation: The information requested on this form is to be completed by the
pool owner or a designated representative of the ownec The completed application is submitted to the local health departrnent for the county in which
the public swimming pool is located. A separate application must be completed for each public swimming pooL Cop�es: Original to be maintained at
the local health department. Disposition: Please refer to Records Retention and Disposmon Schedule for County/District Health Departments
which are published by the North Cazolina 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 52-01-00)
DENR 3961 (Revised 4/03) /
Environmental Health Services Section (Review 4/06) �� W�.L..�Q �
� �.Z� .�, � �Z
� CATAWBA COUNTY, NC
�� ,� 100-A South West Blvd pERMI T RECEIPT
� Newton, NC 28658-
V ��� � Phone: (828)465-8399
° , � "'S� Friday, March 25, 2011
1$ 4Z sM www.catawbacountync.gov
Permit Number: FLI-3-11-16382 Invoice Number: FLI-3-11-273418
Permit Type: Food & Lodging Institutions
Receipt Number:
Work Class: 55 - Year-Round Spa
Site Address: 1607 SE FAIRGROVE CHURCH RD, Conover, NC
APPLICANT OWNER
LA QUINTA INN GLOBAL HOSPITALITY [[[ LLC
1607 FAIRGROVE CHURCH RD SE PO BOX 1022
CONOVER NC 28613 CONOVER NC 28613
828-514-1335
FEES
FEE DESCRIPTION DATE FEE AMOUNT
Pool Insoection Fee 03/25/2011 $150.00
TOTAL FEES $150.00
PAYMENTS
PAYER: GLOBAL HOSPITAL II[ LLC
G LOBAL HOSPITAL II[ LLC
Date Payment Type Check Number Amount Change
03/25/2011 Check 2468 $150.00 $0.00
Memo: NCDL 34941957 EXP 11/23/16 DOB l l/23/80
Total Payment: $150.00
�ennil receipt ;(�e7[,c�c7-Jicc-41 dd-�I772 <1y0c551� I hd-l; i��t 03/25/201 I 12:�9 Page 1 Of 1 I
I