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HomeMy WebLinkAboutFox Ridge Apartments App 500077 05 18 16.PDF (�T—C31 Cv2 WE. �����. ! c c� Ll. �o 50- 1..L1.1 L c i1c.A L'%r( 6 V, or -1Inp-, Lout:6 n e e d( !E G1 . 4blS0 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: rD y_ ! \ I CIG P. i I1 T Street address of pool location: 14'45 U� �; N ) 5J Yr City: County: d _lJ��S. Type of public swimming pool(check one) :1S, Swimming pool ❑ Wading pool ❑ Spa ❑ Other (describe) Date constructed or remodeled: (check one) ❑ Before May 1, 1993 © May 1, 1993 or later 1l Dates of operation: opening date /�����1 (( closing date G1 t��Q' _ —Hours'of operation: opening time - closing time q:0 177,12 OWNER INFORMATION: I IName of owner: N (tr\ - P & Mailing address: ii• i t.r 1)lY. \,iIA) 5 , e-Llo erti NC.,`AY 1 � t Contact person: I Telephone: - to (9�t±' OPERATOR (On-Site Manager) INFORMATION: Name of pool operator: 1 L,',t_1_T75t ) rt W,01 P, Address: C13„1^r'`-ns (AS /it Telephone number: ` ! Pool operator trained by: (check one) !L National Swimming Pool Foundation (Certificate Number: 1 Ci N c (*.VAS Wi G; iyi) ❑ Other(please specify) APPLICATION SUBMITTED BY• Owner or operator: id)I 710 Signature Typed or orinted name Date: "ej i)l/((r, Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in 15A NCAC 18.4.2500 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 Noith 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) • **NOTE: IF ANY DRAIN COVERS. SKIMMER EQUALIZER COVERS)AND/OR Pool Drain Safety Compliance Data PUMP{S) WERE.CH'AN aED Olt SINCE LAST YEAR'PLEASE FILL OUTTHIS FORM:AWNr V I }..� WITH THE APPLICATION** Name of Pool 11 ' A. 11IQ e I .s1 �y '' II y_ \ / r� QQ �/ Address j4)45 4 cR&• by No 435 t'L1 CiVArli1 N O as tap/. Pump System Flow r� Pump Manufacturer 11wt-11 J OX A Model Number •c a L4 t S Maximum Pump Flow (manufacturer's specifications) _gallons per minute aximum 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 rovide supporting evidence for flow reduction) Drain Sump Measurements 8t Sump width: round inches diameter: rectangle inches X inches Sump minimum depth inches Diameter of outlet pipe to pump inches Distance of top (inside) of outlet pipe from bottom of cover/grate inches Drain Cover/grate Data 11 Number of drains on same pumping system Distance between drains (on centers) II pi- . Cover/grate manufacturer war A , model 6 Y )0 4 A e Maximum flow rating of cover/grate I a 5 gpm (floor); NA- gpm(wall) Date drain cover/grates installed: (0. l 15 1 15 Expiration date: /a 15 J Number of operable skimmer equalizers 3 q Equalizer fitting Manufacturer NA model NA Equalizer fitting maximum flow rating NA Date equalizer cover/grates installes: Expiration date Full name of person providing this information Le u�� 4 . I- J [--1 bide, Signature \& UAo dl • ck bY_W^' ' Date 5 II r7 ) i La For instructions please visit the Pool Drain Safety Compliance Website at: http://ehs.ncpublichealth.com/falipti/drainsafety.htm (_; :l CD CATAWBA COUNTY 100A SOUTH WEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT �Via} PHONE: 828.465.8399 Aec was°% Wednesday, May 18, 2016 j84� snt www.catawbacountync.gov PAYOR: FOX RIDGE APARTMENTS FOX RIDGE APARTMENTS PAYMENTS TRANSACTION NUMBER: TRC-674916-18-05-2016 PAYMENT DATE : 05/18/2016 PAYMENT TYPE: Check 6687 INVOICE NUMBER FEE NAME FEE AMOUNT 05-16-328480 Pool Inspection Fee - Seasonal $150.00 TOTAL PAYMENTS : 5150M0 FLI-0000162 CASE TYPE: Food & Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool SITE ADDRESS: 1445 4TH ST DR NW 1-I WY 35, HICKORY NC Establishment FOX RIDGE APARTMENTS. 3609 SWEETEN CREEK RD,CHAPEL HILL NC 27514 F:NONE NONE **NO PEOPLESOFT ACCOUNT ASSIGNED ** Owner WESLEY VAN HEE, 1445 4TH ST DR NW 35, HICKORY NC 28601 Pool Operator LAURA TURNER, 1445 4TH ST DR NW #35, HICKORY NC 28601 B:8283226684C:8283812250 receipt 05/18/2016 1235 Page 1 of 1