HomeMy WebLinkAboutRainbow Childcare Pool App 500064 06 07 16.PDF N.C. Department of Environmental and Natural Resources
Division of Environmental Health 70\BODOCOA
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: �/
Name of public swimming pool: 2Q��[ � CJI�l 1���1�e n
Street address of pool location: I03\ 1 5c(q roue_ CPO C ) 116
City: County: C.nnnve I C &b o \a
Type of public swimming pool (check one) f Swimming pool
❑ Wading pool
❑ Spa
❑ Other (describe)
Date constructed or remodeled: (check one) ❑ Before May I, 1993
❑ May 1. 1993 or later
Dates of operation: opening date June.� \5 closing date 8- 2-L k - \LP
Hours of operation: opening time IC Pint closing time on pm
OWNER INFORMATION:
Name of owner:
Mailing address:
Contact person: G3/4 a-\ e (��3 Telephone: 't2OX' t
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: attle hnsi $ VrA ,y
iC C\-)*
Address: I 031 k:301-qf ON'e. C \ACCh lc\
Telephone number: t)(3l1'ti);C)✓" 5 1 1
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
Se { *aChCd (Certificate Number:
❑ Other(please specify)
APPLICATION S B ITTED BY: �yl
Owner or operator: ��, ) • am _ Ept 1 e 61113�.J
• _t azure T ec or ,rialeed- (me ry
Date: , L�d 'l 1 I JOUJ
Purpose General Statute I30A-282 requires the Commission Ilealth Services to adopt rules governing public swimming pools_The rules in I5A
NCAC 18A2500 require the owner or operator to apply annually for an operation permit for each public swimming pool.This torus 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 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)
**NOTE: IF ANY DRAIN COVERS,
SKIMMER EQUALIZER COVER(S)AND/OR
Pool Drain Safety Compliance Data
PUMP(S)WERE CHANGED OUT SINCE LAST
YEAR PLEASE FILL OUT THIS FORM ALONG
\\ \\ 1 �yt WITH THE APPLICATION**
Name of Pool 2 Q\‘m\rx u1 \ c\ `d tCode Q / cc*ej .._
Address 1 031 \f-5\e-(i yf C O \ �\ \ LC\
Pump System Flow
Pump Manufacturer Model Number c
Maximum Pump Flow(manufacturer's specifications) (> 9 eallons 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 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
Number of drains on same pumping system Distance between drains(on centers)
Cover/grate manufacturer ,model ._
Maximum flow rating of cover/grate gpm(floor); gpm(wall)
Date drain cover/grates installed: • Expiration date:
, Number of operable skimmer equalizers /y,' '/�t
Equalizer fitting Manufacturer 4rjuas /t�ll�/'�r5--P
model /7T/7 /0
Equalizer fitting maximum flow rating � i_i ( -
Date equalizer cover/grates installes: (p 7-026/6 Expiration date (c 7 -a �
U
Full.n...: , .erson providing t rmauon e�'{n-J L h-r i U`Q
Sty•• - Date to 7 � 2- 0i&
- � �.�i� r
For instructions please visit the Pool Drain Safety Compliance Website at:
http://ehs.ncpublichealth.com/fafipti/drainsafety.htm
-PA Co CATAWBA COUNTY
100A SOUTHWEST BLVD
�r- � NEWTON,NORTH CAROLINA 28658 RECEIPT
p�`' mtatordAt
PHONE: 828.465.8399
U `471""71 •a►o' �G Tuesday, June 7, 2016
/842 sm www.catawbacountync.gov
PAYOR: Rainbow Childcare
Rainbow Childcare(Bass, Cathie)
PAYMENTS
TRANSACTION NUMBER: TRC-687675-07-06-2016
PAYMENT DATE : 06/07/2016
PAYMENT TYPE: Credit Card
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-329163 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000154
CASE TYPE: Food & Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 1031 FAIRGROVE CHURCH RD SE RD, CONOVER NC
Applicant DEFAULT APPLICANT„
Manager APPLETREE ACADEMIES, 1031 FAIRGROVE CHURCH RD SE, CONOVER NC 28613
F:NONE NONE
OTHER-IMPORTED APPLETREE ACADEMIES, 1031 FAIRGROVE CHURCH RD SE, CONOVER NC 28613
F:NONE NONE
Pool Operator RAINBOW CHILDCARE, 1031 FAIRGROVE CHURCH RD SE, HICKORY NC 28613
C:8283285211
** NO PEOPLESOFT ACCOUNT ASSIGNED **
receipt 06/07/2016 16:49 Pave 1 or I