HomeMy WebLinkAboutWestminister Park App 500023 04 30 18.tif aofd5oC a3
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N.C. Department of Environmental and Natural Resources
Division of Environmental Health
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION: /
I ,
Name of public swimming pool: ' l i4 : ; /rc , .i Z
Street address of pool location: 19 /
r
City: County: Apr,
Type of public swimming pool (check one) IT Swimming pool
❑ Wading pool
• U Spa
O Other (describe)
Date constructed or remodeled: (check one) ❑ Before May 1, 1993
U May ], 1993 or later
\, Dates of operation: opening date JIM( closing date T r
Hours of operation: opening time ,9 fl erM closing time ,'r 'CO 1.41
OWNER'INFORMATION:
•
\ Nalne of owner: _ . )111 A. -
••.;*- Al/r
Mai ling address: 13 71,,x" Lam- 4.,47,— • W51-- ---
...es G
Contact person: ` a `tTelephone:
OPERATOR
(On-Site.Marra ter) INFORMATION:
Name of pool operator: . WO L I.(.n I glk\
Address: at i iN . r ttn.+r—r S+ k t J c_.o r v� N L dg6 o f
Telephone number: sa O - 3 a a 1 L L r �1
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
X(CertircateNumber: 03 e) LLl ?GI •S� )
U Other(please specini)
APPLICATION S •BMITTEA BY: � I_1 I
Owner or operator: 7 J ^ l 1Y1 {lV"� t Jr'pUtY _ CJ 1 c}1+
Signature, Typed or rinsed rain-_
Dale: t �sI 0 1
Purpose General Statute 130A•2E2 requires the Commission Flealih Service;to adopt rules governing public swimming pools.The noes in ISA
NCAC 15.4.2500 require the owner or operator to apply normally 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 rcgtestad on this form is to be completed by the
pool owner or a doSinoted rcpresentalive of the owner.The completed application is submitted to the local health department fur the county in
which the public swimming pool is located. A separate application mus: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 L•nvironmcntal Health,Dcpanmcnt of Environment end Natural Resources. 1630 Mail Service Center,Raleigh,NC?7699-163
01-00) (Cow ror 52-
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DENR ion mt..{.,d 1/ni‘
Pool Drain Safety(VC13)Compliance Data Completed form must
PERMIT CANNOT BE ASS ti l) IF FORM IS INCOMPLETE he submitted with
A separate form is required for each pumping system.
j� '��.}I- y� application
Name of Pool '',//�'��I" '�`(� I in I f I ,s-kr-
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Address a 10 5 I V , C_:{1 -c.r S�, ' l I Aeon ii id c a 2 6 b 1
FORM COMPLETION—A separate Pool Drain Safety Compliance Data farm must he completed and submitted
for each individual pool at a facility including spas,wading pools,and other pools.
I. Pumgylow y�r�� <n /_ (� \/ C\
Pump Manufacturer C 6 Model eJSR o I � X 15Hors epnwer I ' �J
Maximum Pump plow. Maximum flow rate/row/worn cm-yr 9 0 —gpm. (Provide supporting evidence if flow reduction)
2. Drain Saran Measurements This is the area under the floor drains, if field built sump may need to remove drain cover one dine to measure,
(Check here if sumpless then proceed to next section)
p diameter;
Sump shape: Round-width: O inches dircrer; OR Square- inches X inches
t /(
Sump minimae[depthJ_�_ inches Diameter of outlet pipe in sump_ Opt tpl inche.
Disunce of top(inside)of outlet pipe from bottom ol'cover/gram�Li �inches
Sump manufacturer and model ft if available
3. Drain Cover/Crete Data
Number of drains on each pump_D----___ Distance between drains(on centers) 11 / ,,,�
Cover/grate manufacturer Nig Int r ,model �l(r-P I xLH J�C ,Lifespan:_5 y ,�
Maximum flow rating cleaver/grategpm(Moor); m "_'
1l�..___ gran(wall)
ri
Date drain cover/grates installed a0 I , EXPIRATION DATE: ( o(,�
E2a
4. ligoaliztr Covell
Number of a.r :skimmer equalizers U OR nave the equalizers been disabled'? YES/NO
Equalizer feting Manufacturer . _, model __ , Lifespan_______
Equalizer lining maximum flow rating
Deis equalizer cove/gates installed: EXPIRATION DATE:
5. Snfeh'Va4Rllnl Release System($VAS}_.SVRS required i f dual drains tire closer than 3 feet on center or pump has n single drain with
blockable cover or sump,
Safety Vacuum Release System manufacturer- v'VA C_ ___—_
Vacuum line-Choose One
No vacuum line in pool OR
Protective cover on vacuum lines installed before May I,2010 OR
r,0]
Self-closing, self-latching cover designed to be opened with a tool on vacuum lines installed after May I.2010
y14 A \� CATAWBA COUNTY
�\ IOOA SOUTHWEST BLVD
(Lynn NEWTON,NORTH CAROLINA 28658 RECEIPT
1194.2$F � PHONE:828.465.8399
Monday,April 30, 2018
1842 SM www.catawbaeountyne.gov
PAYOR: Westminister Park HOA
\\'estminister Park I10A(13olick, Van)
PAYMENTS
TRANSACTION NUMBER: TRC-3518819-30-04-2018
PAYMENT DATE: 04/30/2018
PAYMENT TYPE: Credit Card
203390503
INVOICE NUMBER FEE NAME FEE AMOUNT
04-18-352349 Pool Inspection Fee-Seasonal SI 50.00
TOTAL PAYMENTS: 5150.00
FL1-0000079
CASE TYPE: Food& Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool
SITE ADDRESS: 2705 N CENTER ST, HICKORY NC
Owner WESTMINISTER PARK BOA.2705 N CENTER ST. HICKORY NC 28601
8:8284462677
** NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator DEBBIE KNIGHT,2773 N CENTER Si. I IICKORY NC 28601
8:8283227665
receipt 04/30/2018 11:33 Page 1 of 1