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Home My WebLink AboutFalling Creek App 500027 05 31 16.PDF RI came N.C.Department of Environmental and Natural Resources' Zo �5 Q Division of Environmental Health APPLICATION FOR SWIMMING POOL OPERATION PERMIT POOL INFORMATION: Name of public swimming pool: Falling Creek Home Owners Association Street address of pool location: 35(0 1 5 N& City: County: Hickory, Catawba 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 May 30th 2016 closing date Sep 5, 2016 Hours of operation: opening time 0900 closing time 2000 OWNER INFORMATION: Name of owner: Falling Creek Home Owners Association Mailing address: 565 36th AVE NE Ray Horyza 578 1416 Contact person: Telephone: OPERATOR (On-Site Manager) INFORMATION: Name of pool operator: Sunshine Pools Address: 2773 N Center St Hickory 28601 Telephone number: (828) 322-7665 Pool operator trained by:(check one) n National Swimming Pool Foundation n (Certificate Number l7 I N C. A a 058 BUT nOther(please specify) APPLICATION,SUB ITTED BY: Owner or operator: &.BQ� U Vefh Wor-h, � Signatur Typed or printed name Date: 51311 Lorb PurposeGeneral Statute 130A-282 requirestheCommission Health Servicestoadopt rulesgoveming publicswimming pools.The rulesin 15A NCAC 1 SA.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 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 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 Departmentswhich 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) 14:41 ii;At. ra, >.- _ r:i.tFt 515 .-x15 C:it ( t _:u>~'o ct't 'irk Pool Drain Safety Compliance Data I Ar 't(r tl t Name of Pool Faia.ny k e ... Pert_ O41 —„,i_E-vtV Address 35a .,cal S4- Or nit, i4iLfi..i.-1 Ali- _4f;1L,o( Pump System Flow // Pump Manufacturer I{CY Li-et A(,y Model Number 5 7 Z G d 57c 7 • Maximum Pump Flow(manufacturer's specifications) 7Q 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 11.Sump width:round ) inches diameter; rectangle inches X inches E.7 te Sump minimum depth 17 Z inches Diameter of outlet pipe to pump a inches et Distance of tap(inside)of outlet pipe from bottom of cover/grate 3 / 2 inches Drain Cover/grate Data (/ Number of drains on same pumping system 2- Distance between drains(on centers) Cover/grate manufacturer ld.%eM ,model US l(-V Maximum flow rating of cover/grate /?1 gpm(floor); I Z gpm(wall) �7 Date drain cover/grates installed: 1- 2 Y_ I c Expiration date: ft_2 #5 - 2 Number of operable skimmer equalizers Equalizer fitting Manufacturer model Equalizer fitting maximum flow rating Date equalizer cover/grates installed: Expiration date__ Full name of person providing this information Signature Date For Instructions please visit the Pool Drain Safety Compliance Website at: http://ehs.ncpublichealth.com/faf/pti/drainsafety.htm HA AR®® ISWGao48COC Rev D CERTIFICATION OF COMPLIANCE Contains: WGio48E, WGio48EBLK, WGio48EGR, or WGio48EDGR Description: 8" Round Suction Outlet Cover Ratings: Floor: 125 GPM_Wall: 72 GPM Open Area: 8.1 sq-in Certified to Comply with Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act codified at 16 CFR part 1450. Initial Certification May 2011. Manufactured: After September 1o, 2009, by a Division of Hayward Industries, Inc. at Ky-A, 214028 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.havwardnet.com. Hayward Pool Products P.O. Box 5ioo Clemmons, NC 27012-5100, Phone: 336.712-9900 httD://www.havward-pool.com/pdf/literature/8inroundCOC.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, J=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.ore/Certified/Pools/Listin• -.. -.. om n 21600&Standard=ASME19o8 Date of Installation: — , -s Suction outlet components ave a finite life, the ver/grate s-Ilould be inspected frequently and replaced at teast-every , Vedn urff found to be-damaged,;broken;cracked, misshlg,-ornot securely 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 HOLES r7;;‘, ‘: I 1 /l fA /� USED ON FOLLOWING SERIES: / \ 0 H ";;S::'.•0OO e;' i WG1030AV PAK2 SP1030AV PAK2 -yam.• 0000000 a WG1048AVPAK2 SP104eAVPAK2 .`' 000000 .O .!-_r% WG1049AVPAK2 SP1049AV PA K2 073/4" -• 0000000 .<:�:; •0000••00000• > WG1051AVPAK2 SP10S1AVPAK2 SUCTION OUTLET 't.U OOOO• •0000 '�U;�� WG1052AV PAK2 SP10524V PAK2 •0000••0000••.- - COVERWG1Q48E .•00000 WG1053AV PAK2 SP1053 AV PA K2 0' 000000 ��`• WGIOS4AVPAK2 SP10S4AVPAK2 t";"--=":�i 000.000 yo i' WGI153AVPAK2 SP1153AVPAK2 •O•• i0• •�� WG11S4AVPAK2 SP1154AVPAK2• ® 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 11/2"above the finished pool surface over an area larger than 4o"on a diagonal. HAARD° ISWG1o48C0C Rev I) CERTIFICATION OF COMPLIANCE Contains: WG1o48E, WGio48EBLK, WG1o48EGR, or WGio48EDGR Description: 8" Round Suction Outlet Cover Ratings: Floor: i GPM_Wall: 72 GPM Open Area: 8,:sq-in Certified to Comply with Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act codified at 16 CFR part 1450. Initial Certification May 2011. 44 Manufactured: A, Export rProccessng Zone WuxibNew DDi District Jiangsu Province d sPRC 214028, China;oor 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.haywardnet.com Record Custodian is Customer Service at www.haywardnet.com. Hayward Pool Products P.O. Box 5100 Clemmons, NC 27012.5100, Phone: 336-712-9900 http://www.havward-pool.com/pdf/literature/8inroundC0C.odf 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, J=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: htto://info.nsf.org/Certified/Pools/ListingComnanv'16.o&Standard=ASME1908 Date of Installation: St, _ // , _• A_. Suction outlet components have a finite life, the cover/grate shout. . $ nspected frequently and replaced at least eve attached. ry 7 Years orif found to be damaged, broken, cracked, missing, or not securely 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 01,‘k•�\ �,. 'I� �; USED ON FOLLOWING SERIES:•f s •00• 00• 4.‘y WG1030AVPAK2 SP1030AV PA K2 s. 000000 • 000000 S WG1048AVPAK2 SP1048AV PA K2 SUCTION 000000.Oi00o0� WG1051AYPAK2 SPI051 AVPAK2 ..U.-TION OUTLET `O 0000•N•p000 U COVER'w GI 048E �"-=-'•0000••0000• _,�' WG1052AVPAK2 SP7052AYPAK2 000000 WG1053AV PAK2 SPI053AVPAK2 ` , 00 000 WG1054AVPAK2 SP1054AVPAK2 .0060 •0• WGI153AV PAK2 SP1153AVPAK2 �� • • WG1154AVPAK2 SP1154 AV PAK2 • o 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 11/2"above the finished pool surface over an area larger than 40"on a diagonal. (.\. y,A CATAWBA COUNTY I'I' CA 100A SOUTHWEST BLVD C NEWTON, NORTH CAROLINA 28658 RECEIPT ,.i;i Pet PRONE: 828-465.8399 v? ' �S' Tuesday, May 31, 2016 842 SM www.catawbacountync.gov PAYOR: FALLING CREEK POOL ASSOCIATION, PAYMENTS TRANSACTION NUMBER: TRC-682629-31-05-2016 PAYMENT DATE : 05/31/2016 PAYMENT TYPE: Check 1196 INVOICE NUMBER FEE NAME FEE AMOUNT 05-16-328871 Pool Inspection Fee - Seasonal $150.00 TOTAL PAYMENTS : 8150.00 FLI-0000081 CASE TYPE: Food& Lodging Institutions WORK CLASS: 50- Seasonal Swimming Pool SITE ADDRESS: 3561 5TH ST DR NE, HICKORY NC Manager FALLING CREEK POOL ASSOCIATION, PO BOX 1349, HICKORY NC 28603 ** NO PEOPLESOFT ACCOUNT ASSIGNED ** OTHER-IMPORTED FALLING CREEK, PO BOX 1349, HICKORY NC 28603 F:NONE NONE Pool Operator SUNSHINE POOLS LLC, 2773 N CENTER ST, HICKORY NC 28601 B:8283227665 SUNSHINEPOOLS@CHARTERINTERNET.COM CHARTERINTERNET.COM • receipt 05/31/2016 12:32 Page 1 of 1