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Home My WebLink AboutHoliday Inn Express & Suites App 500071 04 27 18.tif aoi s000g1 ( N.C. Department of Environmental and Natural Resources 1 _ 0000 i 5q Division of Environmental Health APPLICATION FOR SWIMMING POOL OPERATION PERMIT POO Name INFORMATION: }�"` /�C / Name of public swimming pool: Street address of pool location: /011 C) f Medi City: County: (_..6 Y Lel Cit ; (akin LACLJ Type of public swimming pool (check one) V Swimming pool RECEIVED ❑ Wading pool ❑ Spa APR 27 2018 ❑ Other (describe) JOUNTY Date constructed or remodeled: (check one) ❑ Before May 1, 1993 TAL HEALTH MI' May 1, 1993 or later /�� n Dates of operation: opening date / r l� MS - iP closing date o t ) ,a1017 Hours of operation: opening time - AA closing time 9 yo / 1 OWNER INFORMATION: J Name of owner: _eAo-( L - *1 0 (LI M /r n� 1< ( Yk l (/1a( 75l Mailing address: /OL/ /O'` JJ ?Ltd ( CenovT/Z x �742613 7 Contact person: � (e Telephone: 8,q " C/-65- /O70 OPERATOR(On-Site Manager) INFORMATION: Name of pool operator: -0 •_ Address: my, l o rAla.) e-ca tie • )16i Telephone number: Sia-2 44,66 7370 Pool operator trained by: (check one) L� National Swimming Pool__Foundation (Certificate Number: VJ(p * (c10-)012 ) ❑ Other (please specify) APPLICATION SUB TTED BY: Owner or operator: ( e hon dra 6 L Signature J Typedor prinf ed name Date: 4/ /2'1 1,7 Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in ISA 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 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) DENA 3961 (Revised 4/03) Environmental Health Services Section(Review 4/06) • 1 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 eac h pumping system. application Name of Pool 0,0-1 &' Q-QAci—' L teL/_— Addres / D T — l=ct A/UI / ( ".A —t 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 ,j Pump Manufacturer r _ /A � ._ _ ...• Model NS 907 CD? x / Q Horsepower Maximum Pump Flow. Maximum flow rate from Dunn curve: 2ci 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: inches diameter; OR Square- inches X inches Sump minimum depth inches Diameter of outlet pipe in sump inches Distance of top(inside)of outlet pipe from bottom of cover/grate inches DECEIVED Sump manufacturer and model it if available 3. Drain Cover/Grate Data APR 2 7 2018 Number of drains on each pump Distance between drains(on centers) Li f y'��,y�� /,., CATA\N.Bs COUNTY Cover/grate ma' ndfaCYPe1'"-"•cinDX reXlr�idel SDX -3.5 . Lifespan: 5 i ffln-) EN v ,h".3=`'I'`4ENTAL HEALTH Maximum flow rating of cover/grate gpm(floor): gpm(wall) Date drain cover/grates installed: rk5"9-79-0/1-1" EXPIRATION DATE: 6, 9' • XI9 4. Equalizer Covers Number of operable skimmer equalizers OR Have the equalizers been disabled? 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 blockablc cover or sump. Safety Vacuum Release System manufacturer- Vacuum line-Choose One _ysc No vacuum line in pool OR Protective cover on vacuum lines installed before May I,2010 OR Self-closing,self-latching cover designed toobbc opened with a tool on vacuumvalines installed after May I,2010 Full name of pe on providing th's information ' / Signature � , Date y ' I"' /2 NCDHI-S Revised 10/2016 / v'A CATAWBA COUNTY/L. •�� 100A SOUTHWEST I3LV0 �� NEWTON,NORTH CAROLINA 28658 RECEIPT CJ ‘9s�►e ry PHONE: 828.465.8399 1 91 v��t `'G' Friday,April 27,2018 1842 5M w w.ealawbacnnmVne.gOV- PAYOR: HOLIDAY INN EXPRESS CONOVER LLC, PAYMENTS TRANSACTION NUMBER: TRC-3495840-27-04-2018 PAYMENT DATE: 04/27/2018 PAYMENT TYPE: Check AP034980 INVOICE NUMBER FEE NAME FEE AMOUNT 04-18-352305 Pool Inspection Fee-Seasonal $150.00 TOTAL PAYMENTS: $150.00 FLI-0000158 CASE TYPE: Food& Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool SITE ADDRESS: 104 10TH ST NW,CONOVER NC Owner LEROY LAILPIEDMONI-CENTER ASSOC. LLC, 104 10TH SI'NW,CONOVER NC 28613 13:8284657070 Paid By HOLIDAY INN EXPRESS CONOVER LLC.2258 I IWY 70 SE, HICKORY NC 28602 **NO PEOPLESOFT ACCOUNT ASSIGNED** Pool Operator BRIAN NICKINNEY, 104 10TH ST NW,CONOVER NC 28613 8:8284657070 receipt 04/272018 10:43 Page 1 of 1