HomeMy WebLinkAboutCross Country Campground 500013 05 04 16.TIF FL:ark)
N.C. Department of Environmental and Natural Resources _
Division of Environmental Health �l t�
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: /'
Name of public swimming pool: j Z(`O S enu n4 rQo1 .- and
Street address of pool location: lobs 5-(1 Li 15 t p6�
City: County: b nV ez ( _n W bQ_
Type of public swimming pool (check one) Swimming pool
❑ Wading pool
❑ Spa
❑ Other (describe)
Date constructed or remodeled: (check one) ❑ Before May I, 1993
❑ May I, 1993 or later
Dates of operation: opening date IN/1G1 I ( , Ui(a closing date UCA I1 a01 (D
Flours of operation: opening time C):00 Ayyt closing time Q 30 err.
OWNER INFORMATION: //`��0 �+
Name of owner: G"0S5 Lun Can I(g1"nctnd
Mailing address: 1p?St, K1 ISO task 11 QC)en4ey Ylo 2?03 -
Contact person: I Telephone: Se)8 455 (Nvag
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: a • So „L tic Cu l l0 . ..
Address: 61614. Wc-FU.r.. 4-W3 (a a S 9 Itto 1 5o E
Telephone number: dab 455otoag
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Certificate Number:
L Other (please specifi) Qq unit c Teat n, ri rent-e/
APPLICATION SUBMITTED BY:
Owner or operator: LCOunek Donna bar
Signature Typed or printed wale
Date:
Purpose General Stabile 1311A-2X2 requires the Commission I leahh Services to adopt rules governing public swimming pools.The odes in I 5A
NCAC 18A22500 require the owner or operator In apply annually for an operation permit for each public seinmling pooh This limo is to allow
owners or operators of public swimming pools to apply for permits. Preparation:The information requested on this form is to he 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 applicaion must he completed for each public swimming pool. Copies: Original to be
maintained at the local health department. Disposition: [lease refer to Records Retention and Disposition Schedule for County/District health
Departments which are published by North Carolina Division all lislorical Resources.Reorder Additional Fors may he ordered from: Division
of Environmental Health. Department of Environment and NWOra1 Resources. 1630 Mail Set-vice Center,Raleigh. NC 27699-1632,(Courier 52-
01-00)
DENR 3961 (Revised(1/1(3)
Environmental Health Services Section(Review 4/061
**NOTE: !F ANY 14t;3;' COVER 3,
SW:110FR EO.=a?tis'aR:::; 7.:W ANY OR
Pt/FANS)WERE CHAr+CEE. GUT SINCE LAST
Pool Drain Safety Compliance Data YEAR PLEASE FILL OUT TH,s F(i tiJ n.Lflir .
l_ /1 WITH THE APPLICATION**
Name of /Pool C,((tJSS CC�Un t�tA li(LYCi7Ylci
Addresstoasy f'ku)•-r I50 L 1 'hen ivc- 1 nc a203 }
Pump System Flow `� p
Pump Manufacturer i 9 Wa rd Sl Model Number ��e 3 I WI
Maximum Pump Flow(manufacturer's specifications) 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 inches diameter; rectangle I , inches X I inches
Sump minimum depth to i 5 inches Diameter of outlet pipe to pump 4 inches
Distance of top (inside) of outlet pipe from bottom of cover/grate 149 .6 inches
Drain Cover/grate Data
Number of drains on same pumping system j Distance between drains(on centers)
Cover/grate manufacturer dt\tAct S fr.r , model R IA Ito X XX
Maximum flow rating of cover/grate 4 4 gpm (floor); gpm (wall)
Date drain cover/grates installed: 5 -1 3" d01 c{ Expiration date: 5-I 3 --1
Number of operable skimmer equalizers Non C
Equalizer fitting Manufacturer model PA„yjed
Equalizer fitting maximum flow rating
Date equalizer cover/grates installes: Expiration slate
Full name of person providing this information_OOfhn /-)G t7
Signature 49021i✓t/a kOO Date
For instructions please visit the Pool Drain Safety Compliance Website at:
http://ehsincpubhchealrh.com/faf/pti/drainsafety.htm
p,A CATAWBA COUNTY
�� 100A SOUTHWEST BLVD
� ` NEWTON, NORTH CAROLINA 28658 RECEIPT
d+ reap PHONE: 828.465.8399
-4 I Wednesday, May 4, 2016
1842 SM WWw.catawbacountync.gov
PAYOR: CROSS COUNTRY CAMPGROUND, Inc.
CROSS COUNTRY CAMPGROUND, Inc.
PAYMENTS
TRANSACTION NUMBER: 1RC-666707-04-05-2016
PAYMENT DATE : 05/04/2016
PAYMENT TYPE: Check 05344
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-327943 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : 5150.00
FLI-0000070
CASE TYPE: Food & Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool
SITE ADDRESS: 6254 ENC 150 HWY, DENVER NC
Establishment CROSS COUNTRY CAMPGROUND, INC., 6254 E NC 150 HWY, DENVER NC 28037
F:NONE
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Owner WRAY FRAZIER, 6254 ENC 150 HWY, DENVER NC 28037
Pool Operator DONNA DAY, 2576 WESTVIEW ACRES AVE EXT, HICKORY NC 28601
C:8284550629
receipt 05/04/2016 11:25 Page 1 of 1