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Home My WebLink AboutCross Country App 500013 04 20 18.tif N.C. Department of Environmental and Natural Resources 500013 Division of Environmental Health L�.aUJ`J rn0On0 APPLICATION FOR SWIMMING POOL OPERATION PERMIT I POOL INFORMATION: C Name of public swimming pool: f0 SS Cu n-{,c�� Co me Street address of pool location: _LP2 5_9 H-}yv_ _I_)5 o C`, City: County: Dented `^Li'f-Gw 1)0- Type of public swimming pool (check one) 1J/ Swimming pool ❑ Wading pool ❑ Spa ❑ Other (describe) Date constructed or remodeled: (check one) 13efore May 1, 1993 ❑ May 1, 1993 or later Dates of operation: opening date closing date OCf I aOl Hours of operation: opening time 9; 00 A-rn closing time 9,So pry,_ OWNER INFORMATION: CoName of owner: Cru Ss Cati.�.,� Mailing address: (y�S'� �uyiso JDP ruts,- NC 480 3 1- Contact person: 1_O an&—C)m1 Telephone: Sa9 LI SS 404)e9_ oc�l OPERATOR (On-Site Manager) INFORMATION: n H 1-1 S 3-S$`1 3- o( ce Name of pool operator: Dd n eta Do `-K}p, ) me rig i i ro u ii Address: 01S}(i Lot-bac,r /kr e N ( SV 3 60 C henuc- Telephone number: 0a8 955 oca 9 Roy -4e 3- S Pool operator trained by: (check one) ❑ National Swimming Pool Foundation (Certificate Number: CT Other (please specifj) _a_944Q31'-elfrai Cen APPLICATION SUB 'FEED BY: Owner or operator: J2n nr..• bGy Signature Typed or rinted name Date: y, 3�,� Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in 15A NCAC ISA.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.'rhe 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 arc published by Nord]Carolina Division of Historical Resources, Reorder:Additional Forms may be ordered front 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) Completed form must Pool Drain Safely(VGB)Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE be submitted with COeparate form is required for each pumping system. application Name of Pool C Co $S (,.. U nkti Ce r peiti -la rtd Address (Da 5 (4 Ftute1 Iso h _ Otnieef NC aa033- FORM COMPLETION-A separate Pool Drain Safety Compliance Data form must be completed and submitted for each individual pool at a facility including spas,wading pools,and other pools. I. Pump Flow Pump Manufacturer 14c,trl,Ja rd Model it_5 p.1_I,O X_1O l-Iorsepower_l&p Maximum Pump Flow. Maximum flow rate from pump curve: 94 q`n)_epm. (Provide supporting evidence if flow reduction) 2. Drain Sump Measurements This is the area under the floor drains, if field built sump may need to remove drain cover one time to measure. (Check here if sumpless ,then proceed to next section) Sump shape: Round-width: inches diameter; OR Square- l a inches X I_ainches Sump minimum depth 10 s S inches Diameter of outlet pipe in sump 14 inches Distance of top(inside)of outlet pipe from bottom of cover/grate 10 , 5 inches Sump manufacturer and model if if available 3. Drain Cover/Grate Data Number of drains on each pump l Distance between drains(on centers) Cover/grate manufacturer 0(0 ast (1 , model 2Ia 1(0 XXX . Lifespan: Maximum flow rating of cover/grate -1 -144 gpm(floor); gpm(wall) Date drain cover/grates installed: .5- 13- p'lcity EXPIRATION DATE: S'13 -02 019 4. Equalizer Covers Number of operable skimmer equalizers OR Have the equalizers been disabled? ail NO Equalizer fitting Manufacturer . model , Lifespan Equalizer fitting maximum flow rating Dale equalizer cover/grates installed: EXPIRATION DATE: S. Safety Vacuum Release System(SVRS1—SVRS required if dual drains are closer than 3 feet on center or pump has a single drain with blockable cover or sump. Safety Vacuum Release System manufacturer- Sfi. I sQ 500 Vacuum line-Choose One No vacuum line in pool OR x•••••"--Protective cover on vacuum lines installed before May I,2010 OR Self-closing.self-Iat ching cover designed to he opened with a tool on vacuum lines installed after May I,2010 Full name of person providing this information Do h-naD a Signature �(/ y_lp, Date /�///3J.3 NCD1.11-IS Revised 10/2016 (.1v2z. CATAWBA COUNTY 100A SOUTHWEST BLVD NEWTON.NORTH CAROLINA 28658 RECEIPT PHONE:828.465.8399 Friday,April 20,2018 7842 SM xvww.catmvbacountync.gov PAYOR: CROSS COUNTRY CAMPGROUND, Inc. CROSS COUNTRY CAMPGROUND.Inc. (Day,Donna) PAYMENTS TRANSACTION NUMBER: TRC-3443693-20-04-2018 PAYMENT DATE: 04/20/2018 PAYMENT TYPE: Credit Card NCDL-7561446 DOB- 1/22/70 EXP- 1/22/26 INVOICE NUMBER FEE NAME FEE AMOUNT 04-18-352015 Pool Inspection Fee-Seasonal S150.00 TOTAL PAYMENTS: S150.00 FLT-0000070 CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool SITE ADDRESS: 6254 E NC 150 HWY, DENVER NC Owner CROSS COUNTRY CAMPGROUND,INC.,6254 E NC 150 HWY, DENVER NC 28037 B:7044835897C:8284550629 F:NONE **NO PEOPLESOFT ACCOUNT ASSIGNED** Pool Operator DONNA DAY.2576 WESTVIEW ACRES AVE EXT, HICKORY NC 28601 C:8284550629 I'ool Operator GARY MCCULLOUGH,6254 E NC 150 HWY 300. DENVER NC 28037 C:7044835897 receipt 04/20/2018 11:19 Page I of l