HomeMy WebLinkAboutCreekside 500054 Pool App 04 18 16.TIF PJI- ILIA
N.C. Department of Environment and Natural Resources 201 sSCll ��y
Division of Environmental Health 9
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: C1rPLKSiC1 �(XtYl tY(eot t 1 nrAe U
Street address of pool location: `{ `�1 \O * b\VCl Mk)
City: kaH County: U-'
Type of public swimming pool: (check one) Swimming pool
❑ Wading pool
•
❑ Spa
n Other (describe)
Date constructed or remodeled: (check one) ❑2 Before May I, 1993
❑ May 1, 1993 or later ff
Dates of operation: opening date `S1 3\ 1 D'D ICS_ closing date 1\� \ ao 1 cD
Hours of operation: opening time 1(I 00 C'tvr closing time 00 1 an
OWNER INFORMATION \ A _ -"
Name of owner: C RtC€ . ckckn1P.V` \--ko \eS,
Mailing address: \W1 10-k-\-& 2D ). a '(9
Contact person: \1 r Sr\p._ Telephone: • 3aL(. t-(g35
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: M.('.1n Q o_ G Pkrit-
Address: \'a % @ \c&V e vcRKU K1(Y e l N
C
a'sipo
Telephone Number: %e % - \0 - log v i
Pool operator trained by: (check one) National Swimming Pool Foundation
(Certificate Number: 1(1/ 1.,0\2-)01 )
❑ Other (please specify)
APPLICATION SUBMITT D BY: r vot
Owner or operator: /` -� S� t o '�G
Signature Typed or printed name
Date-: L\1 \ \ OR K(
Purpose:General Statute 130A-282 requires the Commission for 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 the 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)
**NOTE: IF ANY DRAIN COVERS,
SKIMMER EQUALIZER COVER(S)AND/OR
Pool Drain Safety Compliance Data PUMP(S)WERE CHANGED OUT SINCE LAST
y P YEAR PLEASE FILL OUT THIS FORM ALONG
/' n Lam, WITH THE APPLICATION**
Name of Pool CYee(<scG`e ` oCtOr 'at�.V.�
Address n.1-\ St Nod fiLt> 14ACKor1 adCVOI
Pump System Flow
Pump Manufacturer 1--A k Model Number SP30 3Q('JA-2_'
Maximum Pump Flow(manufacturer's specifications) I LLB gallons per minute
Maximum Pumping System Flow is reduced to N Pt _gpm based on:
Measured Total Dynamic Head loss of feet;
Calculated Total Dynamic Head loss of ' feet;
Magnetic flow meter reading of gpm;
Automatic flow limiting valve factory set at opm
(Provide supporting evidence for flow reduction)
Drain Sump Measurements
Sump width: round N1Pc inches diameter; rectangle ) a., inches X inches
Sump minimum depth inches Diameter of outlet pipe to pump oa inches
Distance of top(inside)of outlet pipe from bottom of cover/grate I t inches
Drain Cover/grate Data
Number of drains on same pumping system Distance between drains(on centers) 3T
Cover/grate manufacturer ,U q�( it , model to G-x I032
Maximum flow rating of cover/grate c956 gpm(floor); A) ) A gpm (wall)
Date drain cover/grates installed:1\901?ock Expiration date:
Number of operable skimmer equalizers
Equalizer fitting Manufacturer model
Equalizer fitting maximum flow rating
Date equalizer cover/grates installes: - ' 1 Expiration date
Full name of person providing this information 1l Sho H • b ill OIL 1-
(S!Signature `SL: Date -y�//�
Ot/1
For instructions please visit the Pool Drain Safety Compliance Website at:
http://ehs.ncpublichealth.com/faf/pti/drainsafety.htm
P'A CATAWBA COUNTY
T�, 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE: 828.465.8399
Monday, April 18, 2016
/842 5M www.catawbacountync.gov
PAYOR: CREEKSIDE APTS POOL
CREEKSIDE APTS POOL (BRYANT,TISHA)
PAYMENTS
TRANSACTION NUMBER: TRC-65 763 9-1 8-04-20 1 6
PAYMENT DATE : 04/18/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-327345 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000149
CASE TYPE: Food & Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 1227 10TH ST BLVD NW, HICKORY NC
Contact Person CREEKSIDE APTS POOL, 1227 10TH ST BLVD NW, HICKORY NC 28601
8:8283244935
**NO PEOPLESOFT ACCOUNT ASSIGNED **
OTHER-IMPORTED CREEKSIDE APARTMENT, 1227 10TH ST BLVD NW, HICKORY NC 28601
F:NONE NONE
Pool Operator MICHAEL GENTRY, 1227 10TH ST BLVD NW, HICKORY NC 28601
B:8283244935
receipt 04/18/2016 15:16 Page I of t