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N.C. Dept talent of Environment and Natural Resources Zoe,- ?{
Division of Environmental Health
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool:
Street address of pool location: I C) 01 off_ ST AO__ N C
City: ,41 G`C0 129 County: C ALA`'
Type of public swimming pool: (check one) Er Swimming pool
in 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 NY-0).0 - closing date / 0
Hours of operation: opening time A'cc eta closing time J 0`. 0 0 em
OWNER INFORMATION
Name of owner: �A (\kJ e t 1--1C-0 J`1t r
Mailing address: O1�os- &\ St V e` NE '4i �to✓tI C �eGe1
Contact person: h.LLt nLifnS Telephone: Vjt('—so) -ti(`lL
OPERATOR (On-Site Manager) INFO TION: }
Name of pool operator: 0\n/A) \\
,W
tn`
Address: 'tq\ ' 11\2ctr.a KLettiat DA, CAidcory Arc_ ad6o2
Telephone Number: I 0 S I (
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:(O f\ . • . • C o
-ther (please specify) t-P fn. ac)
APPLICATION SUTTED (� I ,/�
Owner or operator: Vet U 6 nn R Le CR 0 a(3;Ai s
Signature Typed or printed name
Date_: '7_;S.D,o I 0
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)
tggr"c: if ANY(:!,RAN COVER
;>:,1jmm Fa EQUA sER C'O JR,si A'i+Dt/OR
Pool Drain Safety Compliance Data n N F
SUS ?.xESt rtira ePm��C OUT SINCE LAST
Rau ! / '*F"F n EASE"c U,'THIS FORM ALONG
Name of Pool �� ►� 1 0.t�r�A.l h!L ��C)l.� q q/z•' �`�5 t't I.PP CAS.L^+'"
Address \ 0O S— a I .S1- AV t k) E� VI',e,e0 Z, NG a6 60 l
Pump System Flow
Pump Manufacturer I: y�WAKU° Model Number S 1 Zb (r/c�/
'2o
Maximum Pump Flow (manufacturer's specifications) F.-6 gallons per minute
Maximum Pumping System Flow is reduced to 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 gpm
(Provide supporting evidence for flow reduction)
Drain Sump Measurements
Sump width: round S0 inches diameter; rectangle inches X inches
Sump minimum depth inches Diameter of outlet pipe to pump Z 0 inches
Distance of top (inside)of outlet pipe from bottom of cover/grate inches
Drain Cover/grate Data
i
Number of drains on same pumping system Z Distance between drains (on centers)
Cover/grate manufacturer r1 Ay t t- , model YV V' X 10 T 8 F
Maximum flow rating of cover/grate 1 ar gpm(floor); 1\/(A gpm(wall)
Date drain cover/grates installed: SS —II a.-- a0 1�� Expiration date: 'S /2-22
Number of operable skimmer equalizers
Equalizer fitting Manufacturer )V A model
Equalizer fitting maximum flow rating
Date equalizer cover/grates installer: .t..5--42-2_0 Li Expiration date 'Z-.
Full name of person providing this information ALL, t,,l'.eYvs
L 1 .9 t
� 4 a —ao it Signature Date
For instructions please visit the Pool Drain Safety Compliance Website at:
http://ehs.ncpubhchealth.com/faf/pti/drainsafety.htm
if--A
CO CATAWBA COUNTY
100A SOUTHWEST BLVD
rnn1 NEWTON,NORTH CAROLINA 28658 RECEIPT
()Mr$Pe-„ PHONE: 828.465.8399
id �a►a'" �C Monday, April 25, 2016
1842, SKI www.catawbacountync.gov
PAYOR: LA MADELEINE HOMEOWNERS ASSOC
LA MADELEINE HOMEOWNERS ASSOC
PAYMENTS
TRANSACTION NUMBER: TRC-661259-25-04-2016
PAYMENT DATE : 04/25/2016
PAYMENT TYPE: Check 1521
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-327554 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000099
CASE TYPE: Food R. Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool
SITE ADDRESS: 1001 21 ST AV NE, HICKORY NC
Manager LA MADELEINE HOMEOWNERS ASSOC, 1007 21ST AV NE, HICKORY NC 28601
** NO PEOPLESOFT ACCOUNT ASSIGNED **
OTHER-IMPORTED LA MADELEINE, 1001 21ST AV NE, HICKORY NC 28601
F:NONE NONE
Pool Operator JOHN PAUL KNIGHT, 1125 16TH AV PL NW, HICKORY NC 28601
0:8283105111
receipt 04/25/2016 08:19 Pagel oft •