HomeMy WebLinkAboutWaterford Place App 530073 11 01 2017A
N.C. Department of Environmental and Natural Resources FL
Division of Environmental Health I p aoIg 53oo3
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool:
Street address of pool location:
City: County:
Type of public swimming pool (check c
❑ Wading pool
❑ Spa
❑ Other (describe)
Date constructed or remodeled: (check one) ❑ Before May 1, 1993
Dates of operation:
opening date
Hours of operation:
opening time
OWNER INFORMATION:
Name of owner:
mer
Canting address:
Contact person;
('Ynoo
OPERATOR (O n -Site
Name of pool operator:
Address:
Telephone number:
9�May 1, 1993 or later
slaoY Yr -OU 1I closing date
Ann closing time
INFORMATION:
ICS Si u )
-3,q4- 0
Telephone: , Oz -,3)- 7-0n8
Pool operator trained by: (checkone) ❑ National Swimming Pool Foundation
(Certificate Number:
Other��(pyil,ease x /ecify) � s-
APPLICATION SUBMIT ' , �Yf i -t r #�pp 3 14 '7 *r�(0 02012.
Owner or operator: 1 \�c t�S' UI L67
Signature Typed or ince ran e
Date:
Purlwse Oemcml sulfide 130A-267 requires the Commission Health services In adopt rules governing public mviuuning pools The rules in 15A
NCAC 18A.2500 require the rower or opemtoi to upply annually An, un operation pennil fol each public swimming pool. "is farm is to allow
odors or opus tors of public swiouning pools to opply for panuits. Prepuratimc The information regaasted on Iles runt is to be complete;] by the
pant owner or a designntcd rcpresuntutivu ,I the owner. 'I'lit, umnpicted upplicallon Is +ubmilled to the local health department lir the cooly ht
Witch the public swimming pool is tocued A sepurnte applicutinn must be completed for each public swimming pool Copies: Original to be
maintained at the local health depodment. Dispeaition: Pletuo rct'cr to Records Retention and Dlspnsittan schedule for County/Distriel Heollh
Departments which me published by North Carolina Division of I listmical Resources. Rwrdce Additional Forms may be oniured from; Divislon
offinvitomnwnml lleullh, Depnnmenl of Vin,konment find Nu ural Resources, 100 Kid service Ccnter, Raleigh, NC 27699-1632, (Courier Z
01.00)
DGNR 3961 (Revised 4/03)
Environment I Icalth services Smlion (Roviow 4106)
Pool Drain $platy (YCB) Compliance Data Completed form most
PERMIT CANNOT BEISSUEDIFFORM IS'INCOMPLETE be submitted with
A scparato fora is required for each pumping system, application
1. Pump Flow
Pump Manufacturer
Maximum Pump Flow. Max!ntuni flow rale from numn curve: J--7— ypoi. (Provide supporting evidence if flow reduction)
2. Drain Sumu Measure-meuts'I'ltis is the area under the floor drains, If field buil(sump may need to remove drain cover line tine to measure.
(Check here, if sumpless ,r their proceed to next section)
Setup Shupe: Round- width: inches diameter: OR Square-. in%chess A _,-_inches
Sumpmiriimumdepth, _._.�1.�._!nches Diameter of outlet pipe in sump _!/;� inches
r
Distance of top (inside) of outlet pipe from bottom of cover/grate . _�y__ inches
Sump manufacturer and modelIf ifavuilable
3. Drain Cover/Crgtc Data Jp I/, /I
Number of drains on each pump _ _ Distance between drains (on centers) 5 SJ Z
Cover/gratemanul'acimer l�? .9tt , mode! sliX_t - -... I.ifespun:..
Maximum flow rating;ofcover/grate„j �pm (floor); _. ,.. gain (wail)
Date drain cover/grates installed:_ � _ mtRATION DATE: �5 /` J 1 4q -Z
4. Eaualixer Covers
Equalizer filling lvlmtulacturer
Equalizer fitting maximum flow rating
blockable cover or sump.
ORVCS / NO
1 -lave d+c cqunizcrsioen dtsabled't
model 61WW k Litespmt._....
, J
3i ----EXPIRATIONDATE: �lzZ
— SV Its required If dual drains are, closer than 3 feat on center or pump has a single drain with -
Salcty Vacuum Release System manufacturer -
Vacuum line- Chouse One
No vacuum line in pool OR
'rotective cover on vacuum lines installed before May 1, 2010 OR
�1/_ Self-closing, self -latching cover designed to be opened with a toot on vaeuunv litres Installed after May I, 2010
Pull i+mnc of pc o r providing this in'iillation __-_
----
A, 6n1
5lgnatwe—i ,.-YX62-
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i
NCDf 1I1S
Revised 102016
PAYOR:
SIWOSZEK, ALEKS
PAYMENTS
CATAWBA COUNTY
100A SOUTHWEST BLVD
NEWTON, NORTH CAROLINA 28658
PHONE: 828.465.8399
www.catawbacountyne.gov
TRANSACTION NUMBER:
TRC -2262834-01-11-2017
PAYMENT DATE:
11/01/2017
PAYMENT TYPE:
Credit Card
193882907
INVOICE NUMBER
11-17-346326
RECEIPT
Wednesday, November 1, 2017
FEE NAME FEE AMOUNT
Pool Inspection Fee - Year Round $200.00
TOTAL PAYMENTS: $200.00
FLI-0000198
CASE TYPE: Food & Lodging Institutions WORK CLASS: 53 - Year -Round Swimming Pool
SITEADDRESS: 4000 N CENTER ST DR, HICKORYNC
Manager WATERFORD PLACE APARTMENTS, 4000 N CENTER ST, HICKORY NC 28601
Pool Operator ALEKS SIWOSZEK, 4000 N CENTER ST, HICKORY NC 28601
B:8285140002
** NO PEOPLESOFT ACCOUNT ASSIGNED **
.�Cipt 11/01/2017 12:00 Page i of I