HomeMy WebLinkAboutAdrian Shuford Splash Pad App 560001 05 01 18.tif Li WOO
• N.C.Department of Environmental and Natural Resources f a aoiri_ gitef
Division of Environmental Health l� 0
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: AriAr74n. L Sk,i Fara( YMCA- 5PIa.sH- P..d
Street address of pool location: ICB4 Conevcr 11401 P. coa.oaV IVL d-f6C3
City:County: Lon-a.'- r _ Catat..rb._
Type of public swimming pool (check one) LI Swimming pool
❑ Wading pool
❑ Spa
E Other(describe)Seim, pm.a(
Date constructed or remodeled:(check one) ❑ Before May 1, 1993
❑ May 1, 1993 or later
Dates of operation: opening date May 12 2.MY closing date Oct 12x16
Hours of operation: opening time 7: 3 o ft N closing time CI'.312 PtA
OWNER INFORMATION:
Name of owner: yMC k o4_1 a'Fwr-Aer._ Ve(Iay
Mailing address: I(o`( Ccnwt/ Dlv4 a CO.avery NL }t6I)
Contact person: kgV.n. L149ndj+.r Telephone: el - Yb4- bl�O
OPERATOR(On-Site Manager) INFORMATION:
Name of pool operator: C.knI{-evkea L -$aa 1-wylor
Address: liey COM Ovf! Dl-uvI 2- CSOJtt , NL "-Slot)
Telephone number: �7. S( - 913- o`135 _.
Pool operator trained by: (check one) Fr" National Swimming Pool Foundation
(Certificate Number: LPO-- q 1.7715-
❑ Other (please specify)
APPLICATION SUBMITTED"'/rBY:
C^
Owner or operator: 'a I lay-t-r ckc.sl-orher Taylor
Signature Typed or printed name
Date: C)-4- Lott
Purpose General Statute I30A-282 requires the Commission Hearth Services to adopt rules governing public swimming pools.The rules in ISA
MAO ISA.2500 require the owner or operator to apply annually for an operation permit for each public swimming pool.This farm is to allow
owners or operators of public swimming pools to apply for permits.Pteparation: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 switmning pools 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(VGD)Compliance Data
PERMIT CANNOT DE ISSUED IF FORM IS INCOMPLETE be submitted with
A separate form is required for each pumping system. application
Name of Pool SItiJFdld YMC A- Sekst._ p.,„t
Address Uri Conov<r r3(vch R Conover/ M<– AKtt! )
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.
L Pump Flow
Pump Manufacturer pent-a.:/— Model f: 5a 7S1) Horsepower ]-r
Maximum Pump Flow. Maximum flow ratefrom purnv curve: ri0 wpm. (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: d0 inches diameter: OR Square- __inches X inches
Sump minimum depth �_inches Diameter of outlet pipe in sump 6 inches
Distance of top(inside)of outlet pipe from bottom of cover/grate S inches
Sump manufacturer and model It if available .r r ..l-
3. Drain Cover/Grate Data
Number of drains on each pump I Distance between drains(on centers)
Cover/grate manufacturer VD(FG2' .model .Lifespan _.
Maximum flow rating of cover/grategpm(floor): gpm(wall)
Date drain cover/grates installed: EXPIRATION DATE:
4. Equalizer Covers
Number of eve skimmer equalizers .4 OR Have the equalizers been disabled? YES/NO Leto de(N- &a1y efwrfe--
Equalizer fitting Manufacturer ,model ,Lifespan
Equalizer fitting maximum Flow rating
Dane 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
blockahle cover or sump.
Safety Vacuum Release System manufacturer-
Vacuo10 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 otter May I,2010
Full name of person providing this information._Lti Ophcr 1-05.n _rTvlar
Signatureterrialtdt_._,•• .._Date ‘/-9-1of8 _—. .
NCDHHS
Revised 10/2016
cr��`4'� CAfAWBA COUNTY
�G 100A SOUTUWESI DlvD
h 1 ` �'
NEWTON,NORTH CAROLINA 28658 INVOICE/RECEIPT
L PHONE: 828.165.8399
U 7n} �' Monday,April 30,2018
1842 w sw.catawbacounlync.goe
Invoice Number: 04-18-352363 Invoice Date: 04/30/2018
FI.I-04-2017-084168
CASE'TYPE: rood&Lodging Institutions WORK CLASS: 56 Seasonal Specialized Water Recreation
SITE ADDRESS: 1104 CONOVER BLVD E.CONOVER NC 28613
Owner YMCA OF CAIAWBA VALLEY, 1104 CONOVER BLVD E.CONOVER NC 28613
B:8284646130
"NO PEOPLESOFI'ACCOUNT ASSIGNED"
Pool Operator CHRISTOPHER TAYLOR, 1104 CONOVER BLVD C CONOVIIIL NC 28613
C:8284930135
PAYOR: YMCA of Catawba Valley
Adrian L Shuford Splash Pad(Cloninger,Kara)
FEES
FLI-04-2017-084168 FEE AMT DUE AMT
Pool Inspection Fee-Seasonal 042302018 $150.00 $0.00
FEES: $150.00 SOAO
TOTAL FEES: $150.00 $0.00
PAYMENTS
INVOICE NUMBER FEE NAME FEE AMOUNT
TRANSACTION NUMBER: 'FRC-3520171-30-04-2018
PAYMENT DATE. 04/30/2018
PAYMENT TYPE Credit Card
203406410
04-18-352363 Pool Inspection Fee-Seasonal $150.00
TOTAL PAYMENTS: $150.00
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