HomeMy WebLinkAboutLaurel Forest Compliance 2016.TIF N.C. Department of.Health and Human Services FE' - b061)1Le3
Environmental Health Sectiion 0 Doti S 000'78
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of pui?lic swimming pool: LA GI RP I rose,*
Street address of.pool location: )�3I 8+h sr. 1kkVE NE
,
City: ,cLDR..' County: \_ArAW B /S
Type of public swimming pooh (check one) ❑ 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 My a'f c2O)l'v closing date SEQt 6 ao ( Lp
Hours of operation: opening time A-ny'- closing time .Cy M
OWNER INFORMATION
Name'ofOwner: COR�0OIZATIE M&rvtT SE`/IG);S
Mailing address: :TAU `Q3LL p5 N,c�coey RC a84)U3
Contact person: TAO 4 le Telephone: Sa8-32a- 13(011
OPERATOR(On-Site,Manager)) INFORMATION
Name of pool operator: R Cky A o W imAnt
Address: 1-14a8:;IJoRFH CENTEt?,5`TREET ..11 gv ..niC ago.' .
Telephone number: 82-g•- 3 5-Got-,s S •R -1 CEV 1t S28- 31D-5% 5
Pool operator trained by: (check one) ,IS National Swimming m r Pool Found jon
�� 9&S_r;4Q1 _ t\\ \
(Certificate Nube �'
B Other,(please specify)
APPLICATION SUBMITTED BY:
Owner or operator. i`,•_'� :,/�� //t ick___.. . _O_ MA _. __
Signature/ Typed or printed home
Date: 21-5- /6,
DENR3961,(Revised,7/05) i/ 24U
Environmental Health Section (Review 7/08) Jiii2s C`
'ttvO'c: W ANY_l:,>iN C:DUERS,
5+:iMi!Aci?zQUAL;ZE' C'JVER(S)ANC/OR
Pool Drain Safety Compliance Data ws.'r"E'(`) tiy5Rr CHANCIED OUT-SINCE LAST
y1.l›.§.P.102JSE,F;U.)'tTT`;;5'ORM•AEONG
Name of Pool LA
Re I OQ I (( t l I
Address VlleI t�i4 Si- Xkige IVY- hICkoP.") 1`tC
Pump System Flow }� e
Pump Manufacturer f A11 WA2e1. Model Number SP 210 Dri k )
Maximum Pump Flow(manufacturer's specifications) ea 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 epm
(Provide supporting evidence for flow reduction)
Drain Sump Measurements
r7 I
Sump width: round t r'�'1, inches diameter; rectangle inches X inches
Sump minimum depth 3 ,/T inches Diameter of outlet pipe to pump inches
Distance of top(inside)of outlet pipe from bottom of cover/grate 4'h._ inches
Drain Cover/grate Data
80, 11
Number of drains on same pumping system R Distance between`dralinss�(on centers)
Cover/grate manufacturer HAVW AR C\ , model V`1 L=1 1 048 E.
Maximum flow rating of cover/grate ) a gpm(floor); gpm(wall)
Date drain cover/grates installed: AP 9-]L AD I Is Expiration date: APR+L_ 3
Number of operable skimmer equalizers
Equalizer fitting Manufacturer WA t E(Z-W Ay (.09-
model 0 803 KY
Equalizer fitting maximum flow rating \ 0(D CD P 1\1\ p
Dale equalizer cover/grates installes: APR-! L.f ���� Expiration dote I �■ L pr O. 2
Full name of person providing this information jICLy bl)tAiMANS
Signature I Date
For instructions please visit the Pool Drain Safety Compliance Website at:
http://ehs.ncpublichealth.com/faUpti/drainsafety.htm
•
ins'..,~ »e'''4, c I AV) eh-t�t 7 t"- ✓ �7..,, ,—, ,,,,,. .e„..
v. )S',4%, ft '£*''r �� `' a,�+ •a4,✓ .a`{ f P 1, r<� o L -..k.X, �"• •.
°'4 ,a s e e':e,,-s° s M ,," a t>, 3•t. iv: ' s,.:-.,d w 'e∎ eef,<
u aFd 'Y14.471 f4 t %A i',0,4. �r*,F§ l ',e, i Aff. Or , , tS. Wa:n401VPv..1" -'106. k�#. •I hg#KL.A.,.a$r K ¥F4. rS14*.t r
} - as, rest ISWGio SC0C Rev D
Furze a
i rt r. CERTIFICATION OF COMPLIANCE
i Contains: WGZO48E, WGZO48EBLK, W.GIo48EGR, or WGio48ED.,GR
Description: 8" Round Suction Outlet Cover
's Ratings: Floor: 125 GPM_Wall: 72 GPM Open Area:. 8.1 sq-in
c Certified to Comply with Section,1404 of th e,Virginia Graeme Baker Act.(VG B) Pool & Spa Safety Act
codified at 16 CFR part 1450. Initial Certification May 2011.
t Manufactured: After September 10, 2009, by a Division of Hayward Industries, Inc. at K -A, 214028
j Block K4- A, Export Processing Zone Wuxi New District Jiangsu; Province PRC 214028, China; or at
One Hayward Industrial Drive, Clemmons, NC 27012.
Certified by Hayward Pool Products, 62o Division Street,Elizabeth, NJ 07207, Phone 908-355-7995
Contact at www.havwardnet.com
Record Custodian is Customer Service at www.haywardnet.com.
Hayward Pool Products P.O. Box 51oo Clemmons, NC 27012-5100, Phone: 336-712-9900
, http://www.havward-pooLcom/odf/literature/8inrouridCOC.Ddf
•• Date of Mfr: The Lot Number shown on the product label contains the Year&Month of manufacture.
The first number represents the year (ex 1 = 2011) and the second character the month (A=jan,
B=Feb, H=Aug, I is skipped, l=Sep, etc)
Tested to: ANSI/APSP 16 (ANSI/ASME 112.19.8-2007 (addendum 9b-2009)) per Section 1404-of the
Virginia Graeme Baker Act (VGB) Pool & Spa Safety.Act: Tested by NSF International, 789 Dixboro
Road, Ann Arbor, MI 48113, Phone 734-769-8010 in April 2011- Certificate at
` http://info.nsf.org/Certified/Pools/Listings.asp?Company=21600&Standard=ASME14o8
Date of Installation: 14 —?S 16
Suction outlet components have a finite life, the cover/grate should be inspected frequently and
replacedat-teastevery-7yearsorIf-founctto-be damaged, broken,-c racked;'=missing;or norsecurely° ----
attached.'
Hayward Pool Products acknowledges that it is a federal crime to knowingly and willingly make
materially false, fictitious, or fraudulent statements, representations, or omissions on this
certification.
6"
SPACING BETWEEN —*-
MOUNTING HOLES
� \�\\`��sll III1(/I,//� USED ON FOLLOWING SERIES:
P`\:.• • 0 • .r. •
WG1030AVPAK2 SP1030AVPAK2
1t0000000 a // WG1048AV PAK2 SP1048AV PA K2
1. •P 000000 Oi WG1049AVPAK2 SP1049AVPAK2
07 3/4" • �.9 0000000
•0000••00000 WG1051 AVPAK2 SP1051AVPAK2
SUCTION OUTLET J��•.0000•:•••0000 of WG1052AVPAK2 SP1052AVPAK2
•0000••0000• �' WG1053AV PAK2 SP1053AV.PA K2
COVER W 01048 .000000n-,
\- �k000 000�-; ,WG10153AVPAK2 SP1153AVPAK2
•00 �00•
�� • • � WG1154AV PAK2 SP1154AVPAK2
��///r+g,li girl \� �'
a Warning- Suction Entrapment Hazard.
Suction in suction outlets and/or suction outlet covers which are installed in a small area and/or below the surrounding
surface can cause severe injury or death due to body entrapment hazard.
To reduce the risk of body entrapment, installation of the field fabricated sumps must be such that the top of the
mounted cover is a minimum of i 1/2"above the finished pool surface over an area larger than 40"on a diagonal.
vs F w• WAS. 5 V4-1; n ..r%` 3Y. �S3'3 itt ats,K :IMO �1% v *' ew �,.!.', nrV'tj�gAtrni
> '.'-: %h .Tes5!Lk w,"' PS t-in-Ld ,4 t,Ad l mg kV-1c.' k '+ .f` �' axa L'i_, (sl'g r - +2' t '1st V-
6 I Hayward industrial.Drive
(5 #1±`� ` s° " , � Pool Products 4 ��� Clemmons,NC 27012
336-712-9900�� A Hayward Industnes,lnc;Company www.haywardnet.com
CERTIFICATION OF COMPLIANCE .
Contains: WG1048E or WG1048EW Description: 8" Round Suction Outlet Cover
i Ratings: Floor: 125 GPM Wall: . 72RGPM Open Area:_ 8.1 sq-in
Certified to Comply with Section 1404 of the Virginia Graeme Baker Act(VGB) Pool & Spa Safety Act
1 'Test Results can be obtained from:www.Haywardnet.com and/or http://www.nsf.org/Certified/Pools/
t Manufactured: After December 20, 2008,by Hayward Pool Products in Jiangsu Province, China and
;- Clemmons, NC Divisions of Hayward Industries, Inc. 620 Division Street, Elizabeth,NJ 07207,Phone 908-
_'. 355-7995 -
Date of Mfr: The Lot Number shown on the product label contains the Year&Month of manufacture. The
first number represents the year(ex 8 =2008) and the second character the month (A=Jan, B=Feb, H=Aug, I is
skipped, J=Sep, etc)
a`
1 Tested to ANSI/ASME 112.19.8-2007 (addendum 8a-2008)per Section 1404 of the Virginia Graeme Baker
• Act(VGB)Pool & Spa Safety Act. Certified by NSF International, 789 N. Dixboro, Road, Ann Arbor,MI.
48105 1(800)-NSF-MARK.
f Date of Installation: 4'a C. \6 ISWG1048COC Rev B
6"
SPACING BETWEEN
MOUNTING HOLES
i r
''''A '":\ 11110//�j USED ON FOLLOWING SERIES:
•
• 0, ° WG1030AVPAK2 SP1030AVPAK2
1\�' •00 00° ".,/ WG1048AVPAK2 SP1048AV,PAK2• 0000000 •;�;
i'=� •t 000000 e0 WG1044AVPAK2 SP1049AVPAK2
�-. .� 0000000 1/4 -_.4 WG1051AVPAK2 SP1051AVPAK2
X7314 f �, •00000• •0000•
SUCTION OUTLET j.0"0000•:••0000 wit WG1052AVPAK2 SP1052AVPAK2
1' ••0000• •00000 -4, WG1053AV:PAK2 SP1053AVPAK2
COVER WG1048E CVO 00 00 \ WG1054AV:P'AK2 SP1054AVPAK2
" OOOOQO�
�% 0000.000 •'-.r WG1153AVPAK2 SP1153AVPAK2
000 00• •\�, WG1154AVPAK2 SP1154AVPAK2
HAYW ®POOI Products
GLc0LINE
cOf-lRiOLS One source. Every pool.
..
I
- o - re o
4 taco
0 - 8
0
0 0
,nV., • 4. , „..1 WI,
ak
C E
23 0- -P-
,...,
41144 t ..V.; l2,-al ;7,
o
It
la I=
' t 14:4 t•Ott: 0 0.- 944.4 ]ci&t,,, s • 0 0 11 ,O C ._ c ._ 0 E
to .
441-telk oly _ ., 4-1 '4:, ic.?„Itont.. „: ..,...,a, co .-- , r. 0 , ,
7-'`:' I] 0, eultrt:. - t ,„ "lord. ..r4 r.1 < ci a, 1 F‹ u- °
• t.
'-' Ln -0, en 0
° cL o S.
", ,a 3-- x.,,, 4.- 0.......9 A.kir ,..:..*-_, .r*.;..S.,......... cr, a i
1.1 CC -E3 E 3 e
- ▪ '.4x- p r-P-ti, ....t.,,,,,roi nits- , c 'a '-'2
0 -
_,,...,='-ni.... 't,41...,.... ft.t z”....tz. 1*,trk.ot„'W,4,./ ..P R IN w 'E' .E -..% c 1-1;
- toes . 0:4-..: . ,7,4.4 „ ?s. ,,,,'::"Tog.`...,Y.!,, 'it.'"4..„*-- . isa- ot/ ea - t g; a g,-, 0 I' -0:
../ - 6:. 7 .771/2,.: ic-* • '• .fl° - ea •=3 c "*.gr-
'0 x ••0" ' 0'7_4 414 ‘,zr..+, .,,,4,.'s,‘..
I en r in
eq r4 0'4 or cif F-±'-¢''r g., cu 3
- .,!, ›...r-0 - -0 7±-, t t
- •
03 c? c? c`i 2 cc: ti; °' S >-Ir,
.1...< 166.. .. ••-, k`e..,/, ,4 --i 4.7 t::1"4,i,..
lil in Cia in L4 in 4".• til r 12 42 = E
449-4,‘ht/,,"
vs , tm
,Zs IN -,12 ozs CI ' 424,0 Ei 67:-.`,4711....„ 2, 19
a .„ -
-I 0 0 0 - ..t,.-= - - ad =
Cc 0 ret IN
-4- emir'▪ vb.- •." `411 sit IN cl: IN
CO '117 oe"4' = @, T @.) CP
. ,_ 1-tz •' ta „, in ai get 4 I.= .-. 4.-.
.0.1LP C13. 5 ,-,- E
2
,-.."- "I ro '',.= , el.,rq a; ed r.4 JT,3_ .. r;
4.X. iTsi.occ ": =:: co +:, .-, ID -C LI fd ev- f, = ,-.7c0-,--.1 s
1 V.
e■ 3 rel " n3 ',A -
, ....../_‘...„1" ,.. ._,... go ye, KD , et a , .._.. r- -_. r.. -.- 2 .47,.
.T...
;...4 a; a.; a.; a; CU -0 .-.1 °3 °ii"to ''' • ,
r'
4+ --- -■ ''' r E 'as. ,-* a E
gat
t;'-::-EF0';CrAk'
• ea Li 3 3 -
• fath_ - 1, 4E. ;;; a; +.0-, g y,,
• ,,_, o_ o tin 0 kfl la-
t'1
ii
...e,
, ..
r■- c, ,..; re 0
= 0 0, 0,
.0 -
„let040,4”,
CC •-` r;.:--,,• ‘..• 4t,W'‘alit;6r> In to,
Irt al -
-,,„: .,..—ists..1fr *.:- =
r, t, . ..., .,... .. 1 .,
'Nora ,-: i*, ect....•h,:b Atte'''. , .v ta -B tri ,-
07,
--,-,- _ ifantSit la C
use. v, , En es.,,e..t.,....4....• .,....,x, 0 0 ---5. Ti.-3 s,a .5
•--, 72 --- z1/4',„ --
-
7 c... La — =
......, IN eV
= =
= LA IA
E ,..,- ‘o ,,,
i.. - `=•' , ,
O ,.
01 NI =
ca
0
in 1.• La in e• 3
‘16 -.11;:..7-e."‘IN 19.'..I. A iic*Illti INI IN es
a-
o ,
el e le e CD ... ' I
°
4-4 -4. " ."...4.4'ri
xe Z4,4 e -
j Ca Ca 4-c co , 7-, , , ,,,L, •-",‘,942I'l :' 2,7° -2 PI
C
-■ ,,, , ,r''0- ct in a' ,CD p ,1-) -S ,r,,i
eft - le I'1'
,__,e o =
vS rq 4 "v 'rzt,r4 a; = = 113 . .- AI-
M= i'l'etil kil 1Ld la.k '@.) °P @, c? ^' °P • -tel
tori, pr..,-it.ks — ,1 'n t
j -gig : ='.1. %•-• 1 n3 D' cc c, Ln — =
=
‘-' ce.-'4 >::. E 2
75 io,co's' o 4-
co - ;c:,) ,.., , - ,,,,:,
- .c/ e-• ........ r.-
o _ i
./ il.
..
a ra 1--. .1-. .1-
0 CO ra is .
..6 =ga, 2 .- C-, tc ee = a= a I 6) -- E re
ro7/ -: g - --
,
, 1, :4 . a, z .-L.
0 -z ro rsi p .2
'0. Li.i 2 F--.1 ,5 >, , • =-
.- ..`,4 a) ,V, 8 = = =
° 1.'4
r 1, - ''' ° >
01 ° ew— /IIIIIII.!