HomeMy WebLinkAboutTara Woods App 500052 05 06 16.TIF n!.)y
N.C.Department of Environmental and Natural Resources
Division of Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: �-
Name of public swimming pool: Ze R A c )J/90 O//S 40 f .
r
pool /3 So (Ti-4 srN/� g CACg,tyN.cc)& I
Street address of ool location:
City: County: (,4½9M,_)bn
Type of public swimming pool(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 ,'S//yt/ /6 closing date C170//6
Hours of operation: opening time $:o o closing time 8: o 0
OWNER INFORMATION: /�/h� /�
Name of owner: /i9t:p k.; SS /yo-m C vt,✓Nex 4 55
Mailing address: 632 94-A. ST 1/45-Li g t C kb 2-y NC 5(60i
Contact person: J7n i v p I AO R—Al ' Telephone: 8438' 313-)9 3[,
OPERATOR(On-Site Manager)INFORMATION:
Name of pool operator: Z-61.v4/d f,2A,v4- //et/mod
Address: 51 79412: ✓en Sawo 'd lr,/lartevno4T/UC oitt.)2�
Telephone number: gas -3/3 -A86 /
Pool operator trained by: (check one) National Swimming Pool Foundation
rCA
(Certificate Number: c/5F--A0/03B )459 )
❑ Other(please specify)
APPLICATION SUB TTED BY: � � /,//
Owner or operator: / r /YX vmG1m� 7i c o/& NK,C.Nez nd
Si nature Typed or printed name
Date: 5/6//,b
Purpose General Statute 130A-282 requires the Commission Health Services to adopt roles governing public swimming pools.The roles 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 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)
Pool Drain Safety Compliance Data
Name of Pool /i4-/t, /)crr/S 7C7 Oc.thU ere. 4sc .
Address I tip t /Y 60 N i r !G).re y AI C d t o/
Pump System ttbrw '/�
Pimp Mom er / i,Llji°'C.✓ Model Nandror af7
Maxim=Pimp Plow(maantactu is spectficadana) � .� gallons pet minute
Madam 5b.5-7 g mtbased=
Meoswed Total Dyzalalic Head loss of J 1
Wadded Toni Thumb Read loss of —10 feet
Magnetic flow meter reading of ___gpm;
Automatic Saw timi8ngvalve factory set et /VA gpm
(Provldo suppmdag evidence Sir stow rnd bN
Drain Sump Measurements
Sump aldl0c tatted Jo a los dial sec mese tmdies X lames
a//
Bump mtaftmeDdepth 7 Its . Diameter ofoutlespipetopump I i babes
1
Dktemx of top(inside)ofoutlet pipe from bottom ofcoveafpule v7 Inches
Drain Covas/grateThee �
Rumba of drains sainopwoping eystan Dmabetweendrabs(oncntma fo
CCPAterlie 0101111filaMt PmchvyoaNT
.made] _S DIC .1,S
thotatim flew rating of W.cdgate rC _flues Walk I Cla (wala�[
Date chain oovedgetu MA* ") / q i H pitatkm daces: J/ /9// 7 —
Number of opmabie tdcimmer egualimrs A?
Equalizes fitting Maas aoodd
Equalizer iming maxima li vw Ming
Data equalizer wra/gataa emtidles Expiration date
Fellnameofpa®m pwidbagdrlab m�
tm Wca',N.4I C� `t. Aht Hrrini3 /
S!®taaae .eyek;1/ ,4/aonct+nc, Date .576/ /4
For lnsauccons pleas Ask the Pool Drain Sammy Compliance Webetos at
dratesate hen
.42N /Maigi3 00015
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//y A Cp CATAWBA COUNTY
G 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
aPea! PHONE: 828.465.8399
C P 79 Friday, May 6, 2016
j842 SM www.catawbacountync.gov
PAYOR: TARA WOODS POOL
TARA WOODS POOL
PAYMENTS
TRANSACTION NUMBER: TRC-668094-06-05-2016
PAYMENT DATE : 05/06/2016
PAYMENT TYPE: Check 4166
INVOICE NUMBER FEE NAME FEE AMOUNT
05-16-328105 Pool Inspection Fee - Seasonal S150.00
TOTAL PAYMENTS : $150.00
FLI-0000148
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 1330 5TH ST NE#126, HICKORY NC
Establishment TARA WOODS POOL, 1330 5TH ST NE, HICKORY NC 28601
F:NONE NONE
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Manager THORNBURG ASSOCIATES, PO BOX 3443, HICKORY NC 28603
Pool Operator REGGIE'S POOL& MAIN'T& SUPPLIES, 4796 RIVER BEND RD, CLAREMONT NC 28610
C:8283121861
receipt 05/06/2016 13.09 Page I of I