HomeMy WebLinkAboutHickory Foundation YMCA Pool App 500026 04 25 16.TIF Ca
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N.C.Department of Env i ro hmental and Natural Resources
Division of Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: A C go rs, 1-4-0 414_4(0,-1 /o2Cf
Street address of pool location: 10 i' II' f f/'wl J V✓
Sty: County j. /Cop •-46761. 94
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, ,iTypeofpublicswimmingpool(checkone) � Swimmin g p ool o
If 1 I r Ilt I Wadingpool •a�l"r
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Spa r , ,,I °'!r
Other(describe)
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Date constructed or remodeled:(check one) ■ BeforeMayl, 1993
N May 1,1993 orlater •
bates ofoperation: opening date C(-/6 closing date �0 e( /6 �f" �'
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Howsof'o}ieration: opening time S fJin closing time
OWNER INFORMATION: �-
Nameofowner: 11re(<ory t ✓� d�4ro� / MC41
Mailing address: 7OnI ✓ J ST -, 5.1Lp.,ety tnJ
Contact person: ____�I'A✓ __1�1 I /1co Telephone: 412$- 32 q-Z`dfb'
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: /RuL /'Juba
Address: 761 ,I ST 'Se-gre /PivJ
Telephone number: i22- ?Tyr z-$5
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Pool operator trained by:(check one) n National Swimming Pool Foundation
C Ili..',6c-04-4;16--1-46 66 n
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141 r �� CI ��3 R /OO 4 r yr i, n (Certificate Number Q S p
P2 Other(pleasespecifij) 741(/) i ea41f€d
APPLICATION SUBMITTED BY:
Owner or operator: G ; /9A-a / k✓/a
Signal ire Typed or printed name
Date: y— t/ —/ 6
Purpose General Statute 130A-282 requires the Commission Health Services toadopt rulesgoverning publicswimming pools.Therules in 15A
NCAC 1SA.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 operatorsof pudic swimming pods to apply for permits.Preparation:The Information requested on this form is to be completed by the
pool owner ora designated representative of the owner.The completed application is submitted to the local health department for the county in
which the public swimming pod is located.A separate application must be completed for each pudic swimming pool.Copies:Original to be
maintained at the local health department.Disposition:Please refer to Records Retention and Disposition Schedule for County/District Heath
Departments which are published by Nod Carolina Division of Historical Resources.Reorder:Additional Forms maybe ordered from:Division
of Environmental Health,Department of Environment and Natural Resources,1630 Mail Seivice Center,Raleigh,NC 27699-1632,(Carter 52-
01-00)
DENR 3961(Revised 4/03)
Environmental Health Services Section(Review 4/06)
'7,_, _
"NOTE: IF ANY DRAIN COVEnS,
SKIMMER EQUALIZER COVER(S)AND/OR
• PUMP(S)WERE CHANditiOtte zlf CE.tAS'ri"
Pool Drain Safety Compliance Data YEAR`RLEASE FILL JUT TI11.�r3r,.G ii_o;rr;
THE APP ICATION' -
0 Nnmeof Pool T1 C KOYU YJ el drt-1 ra A. y/ACa 10 r ..
Address ?0/ 1 5r fire-ti' lJW �rcKo i /VG ztbo (
Pump System Flow
Pump Manufacturer Ada 6mv,4y 'QYffrdModel Number
Maximum Pump Flowt(manufacturer's specifications) -^G 0.� gallons per minute
1.
I,Maximulm�P limping System Flow is'reduced to gpm'based on r;
4 �I
Measured Total Dynamic Head loss of feet;
- -'-y Calculated'Tolal•Dynamic Head loss of feet; !`
Magnetic flow meter reading of gpm;
,,•Automatic flow limiting valve factory set at gpm „ ■"j`
Provide supporting evidence for flow reduction) '
n Cr,,1, ,+nn luArjQ:,c kocr /o,4 F+/Ste.• �I nt $ p/Ft ;
G�aa,�� .raw RfiJ�- 2 3
Drain Sump Measurements Ka tottea:. -Fo NA O L.0
m .f �Y,
Flow eF Gaup/J.- tIg 9
Sump width: round diameter; rectangle 18 inches X I' inches
Sunip minimum depth ' 9 inches Diameter of outlet pipe to pump 2' inches
pc
Distance of top(inside)of outlet pipe from bottom of cover/grate . 9 inches
Drain Cover/grate Data nn
Number of drains on same pumping system K Distance between drains(on centers) > 3
Cover/grate manufacturer hlfUAF4H 2 , model (A)AV I1(
Maximum flow rating of cover/grate qQ6 gpm(floor); gpm(wall)
Date dram cover/gratesinstalled: 57/6.- /Q - :•Expiration date.. J5'./6 -
k? Numberofoperableskiinmerequalizers �' /a Hy'atptisa./,'S P)°;s '��;`.i �;,, .... ., , . . .. +IP'Rj'I:. �,p+
Equalizer fitting Manufacturer / \\\ model
Equalizer fitting maximum flow rating
Date equalizer cover/grates installes: N Expiration date / Niel
Full name of person providing this information 12q v L. /�/X10
Signature �f 4.1-0 Date 1/_Z4—/
For instructions please visit the Pool Drain Safety Compliance Websice at:
http://ehs.ncpublichealth.comtfaf/pci/drainsafety.htm
4'A C� CATAWBA COUNTY
Ti 4 100A SOUTHWEST BLVD
NEWTON, NORTH CAROLINA 28658 RECEIPT
.)Ku1 �Pn PI-IONE: 828.465.8399
4 777 �C Monday, April 25, 2016
\842 sm www.catawbacountync.gov
PAYOR:
HICKORY FOUNDATION YMCA,
PAYMENTS
TRANSACTION NUMBER: TRC-661664-25-04-2016
PAYMENT DATE : 04/25/2016
PAYMENT TYPE: Check 72729
Received Check at Hky Location
INVOICE NUMBER FEE NAME FEE AMOUNT
04-16-327582 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000080
CASE TYPE: Food & Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 701 1ST ST NW RD, HICKORY NC
Manager HICKORY FOUNDATION YMCA, 701 1ST ST NW, HICKORY NC 28601
** NO PEOPLESOFT ACCOUNT ASSIGNED **
OTHER-IMPORTED HICKORY FOUNDATION YMCA, 701 1ST ST NW, HICKORY NC 28601
F:NONE NONE
receipt 04/25/2016 14:25 Page 1 of 1