HomeMy WebLinkAboutCelery Stalk App 500034 04 23 18.tif N.C. Department of Environmental and Natural Resources RECEIIiEC
Division of Environmental Health APR 2
APPLICATION FOR SWIMMING POOL OPERATION PL+RM7'� 1i11 3 2018
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POOL INFORMATION: Al FiONA1(=n,Tq '?'N7y'
Name of public swimming pool: C ne% CA/4 -` 'ytgl?N
Street address of pool location: •
J33 �� e A 1/�7C�/ N�
City: County: Cie'/pry /ll(/ ectiatthu d0Gy
Type of public swimming pool (check one) / Swimming pool
❑ Wading pool doll
U Spa Jr000 -
❑ Other(describe) FLI. 00-0070
Date constructed or remodeled: (check one) % Before May 1, 1993
pp�� ❑ May I, 1993 or later [ 1/' Q
Dates of operation: opening date B*/t�L/025, 20/P closing datea '/ y, 110/7
Hours of operation: opening time N.OD 4 2I closing time 9 •. OG Pm
OWNER INFORMATION: •
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Name of owner: SO k, `t �at I M -1 N ves hnn �
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Mailing address: '1re_�i c2t7G/ Sliced Ne -llaor , Ale �%Ql
Contact person: \ /Pay Telephone: d Ate.712/1 9716
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OPERATOR (On-Site Manager)INFORI TION: /
Name of pool operator: /-r� /_' ,Ike—
Address: S a //2 rrn /9fry_ Ari - , M /cw' ,1/c 2,6D/
Telephone number: gZ Y- 933 ‘5-9 y
Pool operator trained by: (check one) X National Swimming Pool Foundation
(Certificate Number: C762 - 993-5-96")
❑ Other(please specify)
APPLICATION SUBMIT : / Z------
Owner
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Owner or operator:
!� — Z� nic /-)67,v7 ` _
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TYPed a1�ri��� na�� /� ZED f?
Date: ��
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.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)
Completed form must
Pool Drain Safety(VGB)Compliance Data
PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE be submitted with
A separate form is required for each pumping system. appllC.aF_CF_1V F.f
Name of Pool /P:• $4,,/k. APR 2 3 2018
Address 333 161' kue DNE 41ckl A / CATAW :'.
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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 �— • �A �/
Pump Manufacturer J a C yl z . t Model# �' (/t m / y
7 Horsepower
Maximum Pump Flow. Maximum flow rate/-o,;i pump curve: Z 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)
Sump shape:Round-width: 7 /y inches diameter: OR Square- inches X inches
7
Sump minimum depth •••-S inches Diameter of outlet pipe in sump / 1/ inches
Distance of top(inside)of outlet pipe from bottom of cover/grate 3 �r / inches
Sump manufacturer and model# if available
3. Drain Cover/Grate Data
Number of drains on each pump ) Distance between//drains(on centers) 0
//
Cover/grate manufacturer /VA/ .model_ 9&/O H Ir& . Lifespan: 7
Maximum flow rating of cover/grate / 2 > gpm(floor): —gpm(wall)
Date drain cover/grates installed: /72a7 2 ..2zS_______EXPIRATION DATE: aca®
4. Equalizer Covers
Number of operable skimmer equalizers OR Have the equalizers been disabled? YES/NO
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- 5)ii/6 L f IL coo
Vacuum line-Choose One
aS 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 Mier Mayes I.22010
Pull name of person providing this information ( ////' Q /rz,7� /-1.4'/•j/�- —
Signature - Dte p �7' ZD/ 9_
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NCDHI IS
Revised 102016
sto3A co CATAWI3A COUNTY
I OOA SOUTHWEST BLVD
ET :l ti rt 1 NEWTON.NORTH CAROLINA 28658 RECEIPT
PHONE:828.465.8399
KMond0 itiO, `C
ay,April 23,2018
1842 sM www.cautwbacountyne.gov
PAYOR:
SHOOK ANI)TARLTON INV.COMPANY. Jenny
PAYMENTS
TRANSACTION NUMBER: TRC-3466229-23-04-2018
PAYMENT DATE: 04/23/2018
PAYMENT TYPE: Check 61633
INVOICE NUMBER FEE NAME FEE AMOUNT
04-18-352081 Pool Inspection Fee-Seasonal $150.00
TOTAL PAYMENTS: S150.00
FL1-0000090
CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool
SITE ADDRESS: 333 10TH AV DR NE. HICKORY NC
Manager JENNY SHOOK ANI) IARLI'ON INV.COMPANY.926 2ND ST NE.HICKORY NC 28601
8:8283249780
"NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator LARRY WARNK E.590 12TH AVE NE. HICKORY NC 28601
8:8284556594
receipt 161/232018 11:32 Page 1 oft