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Home My WebLink AboutJameson Inn 500073 VOIDED Pool App 04 15 11.tif . �. ��i - C��G I � 0 N.C. Department of Environment and Natural Resources Division of Environmental Health �� r � S � D � " APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT POOL INFORMATION: Name of public swimming pool: `_ � Street address of pool location: � � � � u � � -� Ciry: � C � County: G�� a�; Type of public swimming pool: (check one) Swimming pool �,'j Wadin ool ` �� l ,�+', ❑ gP � �, ❑ SPa `\ a�\`� i , . .' ❑ Other (describe) �'� � -, � ��\� ,, i .,.,. Date constructed or remodeled: (check one) ❑ Before May 1, 1993 (}1� Q � �� ay 1, 1993 or later ��' � C� �� ",�-� � � closing date �� / � � �� Dates of operation: opening date `� Hours of operation: opening time �� f'L-� closing time �� /'�� OWNER INFORMA� , Name of owner: �� /" " j�� Mailing address: � � J✓ Contact person: C '( � Telephone: 2�` �G� G7"C � OPERATOR (On-Sit ManagQ� O TI . _ 1 L �1�C., ,� G G ' Name of pool operator: / �(ti' � � Address: � i - ✓ � � � Telephone Number. � � `— � Pool operator trained by: (check one) ��National Swimming Pool Foundation (Certificate Number: ) ❑ Other (please. specify) APPLICATION S TEI� � � �' , � Owner or opera � . n ' �� agnature Typ d or printed nam Date — Purpose: General Stat 130A-282 requires Ihe Commission for Heal[h Services to adopt rules goveming public swimming pools. The rules in 15A NCAC 18A .2500 quire the owner or operator to apply annually for an operation permit for each public swimming pool. This fortn is to allow owners or operators of public swimming pools to apply for permits. Prepazation: The infortnation requested on this form is to be completed by the pool owner or a designated representative of the owner. The completed application is submitted to the local health department for the county in which the public swimming pool is located. A separate application must be completed for each public swimming pooL Copies: Original to be maintained at the local health department. Disposition: Please refer to Records Retent�on and Disposition Schedule for County/District Health Departments which aze 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) ` \ � � � � — �� \' i ` '�� C O� � � ' CATAWBA COUNTY, NC �' ] 00-A South West Blvd pERM/ T RECE/PT �' �='" � Newton, NC 28658- � ��► � Phone: (828)465-8399 C.� ," �� ''C Friday, April 15, 2011 1$ 4'Z sM www.catawbacountync.gov Permit Number: FLI-0000160 �nvoice Number: FLI-4-11-274288 Permit Type: Food & Lodging Institutions Receipt Number: Work Class: 50 - Seasonal Swimming Pool Site Address: 1120 13TH AV DR SE, HICKORY, NC APPLICANT � � OWNER IMPORT-APP-PERMIT DEFAULT APPLICANT FEES FEE DESCRIPTION DATE FEE AMOUNT PoolInspection Fee 04/04/2011 $150.00 Poollnspection Fee 04/27/2009 $150.00 Pool Inspection Fee 04/15/2011 $150.00 Pool Inspection Fee OS/22/2007 $150.00 Poollnspection Fee OS/13/2010 $150.00 Pool Inspection Fee 04/23/2008 �150.00 TOTAL FEES $900.00 PAYMENTS PAYER: KIMBERLY W[THERSPOON Date Payment Type Check Number Amount Change 04/15/2011 Cash $150.00 $0.00 Memo: Total Payment: $150.00 pernii� re�eipt ;(�c2��7�d1-Sc?c--l33b-b-Itia-��'��-I I� %0:,��h;.r�x 04/IS/2011 13:44 Page 1 of 1