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Home My WebLink AboutDays Inn Pool App 500100 04 20 18.tif a°i2saO i JC Ftd on- 4013_nais N.C. Department of Environmental and Natural Resources ��_ Division of Environmental Health APPLICATION FOR SWIMMING POOL OPERATION PERMIT POOL INFORMATION: ,� Name of public swimming poo!: � S N 1 tNI- -a- Su S rl/ ckaA , Street address of pool location: I /PI AVE VAt/t t� , N TC)C3J y, 'Ne- 2S'�ilO1 City: County: 11LCA D/C / )) C 2 of Type of public swimming pool (check one) Swimming pool ❑ Wading pool ❑ Spa ❑ Other (describe) Date constructed or remodeled: (check one) ❑ Before May I, 1993 May I. 1993 or later Dates of operation: opening date /C.SAp closing date 0 cp.. 3J _.zO\g Hours of operation: opening time /6 AM closing time 2O pit4.: OWNER INFORMATION: Name of owner: P-'1S IN N 2Z--• SLULT s 'LC 2<D u/ Mailing address: 1 25 13t / 11/R RSCK6}Zkl ,1\3C- 2SSGO Contact person: Z �' ' 4 ` q2 \0 0 OPERATOR (On-Site Manager) INFORMATION: Ce(l - g 6 3T - BOG\-° Name of pool operator: E A rc ( __ Address: 17-25 1311-1 4v/ DA N w � hit( os�t , 1v< - R,}-63 Telephone number: g,7‘55- ' - 43 1 ' 2 )O0 Pool operator trained by: (check one) Cl National Swimming Pool Foundation (Certificate Number: ) ❑ Other (please specif) APPLICATION SUBMITTED BY: n ` Owner or operator: r �P /) IJ/�(01-1 / Signature Typed or printed name Date: 04- ?o - ls2 Purpose Genera! Swoae 1711:\-252 requires the Commission Health Services to adnnt rules governing pl.blic.swimming pools.The rules in 15A NCAC SA2500 require the owner of op:rattle to apply annhat ly fur an operation permit fol each public swiu:mi::0 pool.'i This ;inn is to allow owners or operators of publie swimming pools to ripply for permits.Preparation:The info,nation requested on this form is to be completed by the pool owner or a dCSi014;ed representative of the owner.The completed application is submittec to the iota I health department or the county it which the public swimming pool is luc:rted A separate application rust be completed Ihr each public swimming pool.,Copies: Original to be maintained at the local health. departrnCn:. Disposition: ('lease refer to Records Retention and Disposition Schedule for Count oil)istriet Health Departments whieh are publ sled by Noah Carolina Division of Flistorical lbesources,I(eo:tee::Additional Forms may be ordered from:Division of Environmental Health.Department of Environment and Natural Resources, i 630 Mail Service Center,Raleigh,NC 27699-1632.(Courier 52- 01-0(:) DENR 3961 (Revised 4(C3) Environmental health Services Section(Review 4/06) Completed form must Pool Drain Safety(VCR)Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE be submitted with �J/� A separate form is required for each pinaping system. application Name of Pool c✓ RLA S �� S e.s k\1 c h8/4.7 Address ) 25 1P1\ Nye a0)K . NW , Ni cUo--9c9 , NC ' 2K j 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. Pomo Flow Pump Nitanufacturer �� h� Model ft SP eZ / Horsepower D. Maximum Pump Flow. Maximum flow rate from pump curve: gpm. (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) ll Sump shape:Round-width: DP inches diameter; OR Square- inches X inches 1� 11 it Sump minimum depth 6 ra inches Diameter of outlet pipe in sump cR. inches II Distance of top(inside)of outlet pipe from bottom of cover/grate A- /a inches Sump manufacturer and model ft if available 3. Drain Cover/Crate Data � Number of drains on each pump Distance between drains(on centers) t� pSfri Cover/grate manufacturer 71gOcOgS'i\-ah e,�model V GCB .Se/ll es. Lifcspaic Maximum flow rating of cover/grate 6 o gpm(floor); gpm(wall) Date drain cover/grates installed: Mh-y - 201S— EXPIRATION DATE: " YLlhS 4. Eq ualizer Covers T`L Number of operable skimmer equalizers /A OR Have die equalizers been disabled? YES/NC) Equalizer fitting Manufacturer .model . Lifespan Equalizer fitting maximum flow rating Date equalizer cover/grates installed: EXPIRATION DATE: 5. Safety Vacuum Release System (SVRS)—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- bl/A. Vacuum line-Choose One No vacuum line in pool OR ✓- Protective cover on vacuum lines installed before May I,2010 OR Self-closing,self-latching cover designed to be opened with a tool on vacuum lines installed after May 1,2010 Full name of person providing this information /a (11 Signature Date 111 (((/// NCDI1l IS Revised 10/2016 Instructions for Completion and Submission of Pool Drain Safety Compliance Data.Form Please review the instructions below to ensure the Pool Drain Safety Compliance Data form is properly completed and submitted with all information required. All submissions will be need to be approved and verified by the Health Department prior to the issuance of an operation permit for the pool in accordance with Rule .2539(c). POOLS WITH MULTIPLE PUMPING SYSTEMS MUST SUBMIT A FORM FOR EACII PUMPING SYSTEM. I. PUMP FLOW—Enter the maximum flow from the manufacturer's pump performance curve. Pumpcurves can be found online at http://ehs.ncpublichealth.com/faf/pti/drainsafetv.htm and http://charmeck.org/mecklenburs/county/I-IealthDepartment/Environmental Health/PublicSwimmingPools/Pages/dela ult.aspx\ 2. DRAIN SUMP MEASUREMENTS—Measurements are needed to determine the size of the cover/grate and to assure the sump is deep and wide enough to meet the requirements in the cover/grate manufacturer's specifications. Information on documenting the size of the drain sump can be found at: http://ehs.ncpublicheahh.com/faflpti/drainsafety.htm 3. DRAIN COVER/GRATE DATA—Enter the manufacturer, model, lifespan expiration date and maximum How for the main drain cover(s).Various approved covers can be found under VGB Approved Drain Covers and Equalizer Covers listed at the following website: http://charmeck.org/mecklenburg/countv/HealthDepartment/Environmentall-lealth/PublicSwimminuPools/Pages/dela ult.aspxA or at the drain cover manufacturer's website. 4. EQUALIZER COVERS—Enter the number of operable equalizer line covers, the manufacturer, model, lifespan expiration date and maximum flow for the equalizer covers. Various approved covers can be found under VC 13 Approved Drain Covers and Equalizer Covers listed at the following website: http://charmeck.org/mecklenburg/eounty/HealtliDepartment/EnviromnentalHealth/PublicSwimmingPools/Pages/defy ult.aspx\or at the equalizer cover manufacturer's website. If all equalizer lines are disabled or pool has no equalizer lines, please indicate and provide details on the form. 5. SAFETY VACUUM RELEASE SYSTEM(SVRS)—SVRS is required if dual drains are closer than 3 feet on center or pump has a single drain with a blockable cover or blockable sump. Enter the manufacturer of the safety vacuum release system (SVRS). If using another secondary method of preventing bather entrapment allowed in Rule .2539(b), please attach documentation. 6. VACUUM LINE— If vacuum line ports are present in the pool, please indicate the type of cover(s) on the form. 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. The Health Department understands that the required information and/or measurements may be beyond the scope of owners or operators. In those cases, it is recommended that you contact a Registered Design Professional (Professional Engineer or Licensed Architect) or a knowledgeable pool professional to assist you in completing the form. �1P'A C do CATAWBA COUNTY y G� IOOA SOUTHWEST BLVD (- a NEWTON,NORTH CAROLINA 28658 RECEIPT i►� PHONE: 828.465.8399 v C..� "J�� v�sv Friday,April 20,2018 I8 42 sm eww.cauvbacomnync.go PAYOR: DAYS INN POOL DAYS INN POOL(Patel, Dee) PAYMENTS TRANSACTION NUMBER: TRC-3446028-20-04-2018 PAYMENT DATE: 04/20/2018 PAYMENT TYPE: Cash INVOICE NUMBER FEE NAME FEE AMOUNT 04-18-352037 Pool Inspection Fee-Seasonal $150.00 TOTAL PAY M ENTS: S150.00 FLI-07-2013-039542 CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming l'ool SITE ADDRESS: 1725 13TH AV DR NW, HICKORY NC 28601 Owner DAYS INN POOL, 1725 13TH AVE DR NW.HICKORY NC 28601 13:82843121000:8286381040 "NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 04/20/2018 15:17 Pape 1 of 1