HomeMy WebLinkAboutOakwood Apt Pool App 500099 06 07 16.PDF FC )6 II
N.C. Department of Environment and Natural Resources �v j-� —
Division of Environmental Health
APPLICATION FOR PUBLIC SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
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Name of public swimming pool: �1Gt ` P`^' ��-S
Street address of pool location: I s Du nd a t
City: Nerof. County: Cja � ~'���
Type of public swimming pool: (check one) Swimming pool
❑ Wading pool
❑ Spa
in Other (describe)
Date constructed or remodeled: (check one) a- Before May 1, 1993
❑ May 1, 1993 or later I
Dates of operation: opening date /V - / _ closing date J o 3 1 - )
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Hours of operation: opening time '00 (k1A closing time q `)D PfiA
OWNER INFORMATION
Name of owner: VP, 5+0 r\-k. no? nnv,) At
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Mailing address: r �l out n d art c521-
Contact person: Cjib Iai e S Telephone: a 11(4 7 0
OPERATOR (On-Site Manager) INFORMATION:
Name of pool operator: C1 Y \
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Address: I LI ��cin Jet� - (Vt I ° � Ivc
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Telephone Number: -'— - 19 - 7oo �ag-
Pool operator trained by: (check one) ® National Swimming Pool Foundation
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(Certificate Number: \-3C-1* � 01 g P .
❑ Other (please specify)
APPLICATION SUBMITTED BY: J� /l
Owner or operator: l 'J CO10 I Q'h. (
Signature Typed 99r� printed name
Date : C� - 7- ( La
Purpose:General Statute I30A-282 requires the Commission for Health Services to adopt rules governing public swimming pools. The rules 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 the 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) RECEIVED
Environmental Health Services Section(Review 4/06)
JUN 0 7 2016
CATAWBA COUNTY
ENVIRONMENTAL HEALTH
**NOTE: IF ANY DRAIN COVERS,
SKIMMER EQUALIZER COVER(S)AND/OR
Pool Drain Safety Compliance Data PUMP(S)WERE CHANGED OUT SINCE LAST
O //�� YEAR PLEASE FILL OUT THIS FORM ALONG
W(' '300d .up�h,, ,,�{s WITH THE APPLICATION**
Name of P{o�ol C �{ I A 1�� L�
Address IL1J 1 ourel t, ' s4rtt Ne,✓-)4° / p c 02E057
Pump System Flow a
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Pump Manufacturer Na jCAJ rel Model Number r,d-fi e 1 R (
Maximum Pump Flow(manufacturer's specifications) ) 2-S 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
Sump width: round 8_ inches diameter; rectangle inches X inches
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Sump minimum depth 1 Z 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)
J
Cover/grate manufacturer , model
Maximum flow rating of cover/grate ) ZS- gpm (floor); G__________gpm(wall)
Date drain cover/grates installed: 2 0 (5 Expiration date:
Number of operable skimmer equalizers 2
Equalizer fitting Manufacturer 11199 ward model
Equalizer fitting maximum flow rating
Date equalizer cover/grates installer: z O ) Expiration date
Full name of person providing this information
CAA4-611i.,
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Signature �t� Date
RECEIVED
For instructions please visit the Pool Drain Safety Compliance Website at:
http://ehs.ncpublichealth.comlfaf/pti/drainsafety.htm
JUN 0 7 2016
CATAWBA COUNTY
ENVIRONMENTAL HEALTH
A Cp CATAWBA COUNTY
7" {� G 100A SOUTHWEST BLVD
,.=-1 Mn vo N NEWTON,NORTH CAROLINA 28658 RECEIPT
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� �w ` PHONE: 828.465.8399 Tuesday, June 7, 2016
84Z set www.catawbacountync.gov
PAYOR: OAKWOOD APARTMENTS
OAKWOOD APARTMENTS (Couture, Enola)
PAYMENTS
TRANSACTION NUMBER: TRC-687127-07-06-2016
PAYMENT DATE : 06/07/2016
PAYMENT TYPE: Check 79155
Received by mail
INVOICE NUMBER FEE NAME FEE AMOUNT
06-16-329123 Pool Inspection Fee - Seasonal $150.00
TOTAL PAYMENTS : $150.00
FLI-0000151
CASE TYPE: Food & Lodging Institutions WORK CLASS: 50 - Seasonal Swimming Pool
SITE ADDRESS: 745 BOUNDARY ST,NEWTON NC
Contact Person ENOLA COUTURE, 745 BOUNDARY ST 100, NEWTON NC 28658
B:8284643170
Establishment OAKWOOD APARTMENTS, 745 BOUNDARY ST, NEWTON NC 28658
F:NONE RENT @KEYSTONOAKWOOD.COM
** NO PEOPLESOFT ACCOUNT ASSIGNED **
Owner EWT 27 LLC,99 FISHERV ILLE RD,CONCORD NH 03303
Pool Operator PETER PRIES, 745 BOUNDARY ST, NEWTON NC 28658
B:8284643170C:7047400622
receipt 06/07/2016 09:51 Page 1 of 1