HomeMy WebLinkAboutHickory YMCA App 530064 11 04 09.TIF
N.C. Department of Environmental and Natural Resources
Division of Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: 1C Leh A kc
Street address of pool location:
City: County: \\C C 1 r✓ l ~ Y,a
Type of public swimming pool (check one) 0 Swimming 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 closing date
Hours of operation: opening time 719 closing time
OWNER INFORMATION:
Name of owner: ~I 1 ~CIL eVL1 - ~L. Ckajia'1
Mailing address: " 1 CU \ l s-- 2-~ ~~L) S I C Y"STl N C Z 6 1
Contact person: Telephone:
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator:
Address:
Telephone number:
ZT~
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:
1 Other (please specify) ~nCr1
APPLICATION SUB VI TE Y: f~
Owner or operator: h / I S n~ r
Signature Typed or printed name
Date: /o /d t I Uq
Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing 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 apply for permits. Preparation: The information 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 Retention and Disposition Schedule for County/District Health
Departments which are published by North Carolina 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) V liU~w
~A COQ CATAWBA COUNTY, NC
f .k 10 South West Blvd
I ~ Newton, NC 28658-
Newton, PERMIT Il Y V OI CG
0 Phone: (828)465-8399
Wednesday, November 4, 2009
1 2 sm www.catawbacountync.gov
84
Permit Number: FLI-0000190 Invoice Number: FLI-11-09-256964
Permit Type: Food & Lodging Institutions Receipt Number: RCPT-000431
Work Class: 53 - Year-Round Swimming Pool
Address: 701 1ST ST NW, HICKORY,
APPLE--- 1 C' ~ NT IIvIPORT-.111(1-l'LI,1\11T ULhAI_ 1_ F ,AI'PI,1( ,AN I ~UIENS{YOUNG ~
PO BOX 280
CONOVER NC 28613
FEE DESCRIPTION DATE FEE AMOUNT
Pool Insueotloll Fee
J, lUUy ` `$200:00
7'S 1
1, 74
Poollnspection'Fee`
0%28/2008 $200:00
Pool Inspecfton Fee' , wx
' 11/19/2007 $200.00
TOTAL FEES $600.00
Date Payment Type Check Number Amount Change
11/04/2009. Check 054436 0
ti n240 40 ` $0.00
0
Memo: NCDL 31151593
Total Payment: $200.00
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