HomeMy WebLinkAboutAdrian L Shuford App 530057 05 01 18.tif N.C.Department oflinvironmental and Natural Resources
(XXk�l
Division of Bnvlmnlnaulal IIcallh
APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: ftL_.4k ,/4orrc_ YAC Pr Fool_
Street address of pool location: 1/°L Conovv 131.4 S. Conover vtlC AK61}
City: County: Conover / __-titer-4 _
Type of public swimming pool (check one) C< Swimming pool
❑ Wading pool
I Spa
I I Other (describe)
Date count]tel ed or remodeled: (check one) Cl Before Mayl, 1993
❑ May 1, 1993 or later
Dales of operation: opening date To_ I 201I closing date Pc 31 lay
hours of operation: opening time $':o0 A closing time _ `1 g P _-
OWNER INFORMATION:
Name of owner: YM.0 A- of Ca+a..LIS _valley _
Mailing address: (19- (vnQ✓tl QlvA a. _ ZakVicr 3_
Contact person: l(aro- Llon•nj a r Telephone: 841 —YGV- 6/3o
OPERATOR(On-Site Manager)INFORMATION:
Name of pool operator: Lhn3toQber Lo y. Tckyte,- _
Address: flay Co nose./ l3l,vd e- C opoyey_NC._o1 X4/3
Telephone number: ` 2-c (k o ci 3S
Pool operator trained by: (check one) L3 National Swimming Pool Foundation
(Certificate Number: ( PO ''167J/r_ D
❑ Other(please.sped(*)__
APPLICATION SI TWITTED BY:
Owner oroperator: ( .rte �'-. �''L _Cko3f—key TayLa�
Signature Typed or pmntedppname
Date: '-9 - 2.f.-(a_._ .___..
]mimes Gensral Mande 130A-292 laminas the Co,nmisslml Health services to adopt rules governing polder swimming pone.The noes in ISA
NCAC 1&A2500 require the owneroperator Iii apply annually for an operation nm it for each public swimming pool,This town is ro allow
owners im
r oold al drsoe of public pioson ti pool]to apply for linings.Preparation: n information to he lee nn eda health cep is inm be gra OD a by the
poolownerd G 'Idmol mf of Antamer.pap o ]Holli C dvfr eac to the localminIl I If Wrco to u
maintainer tine, 'nd dupeol Id_Axsiti t ics. r noat Iry ion and Dish position
swimming r aunty.Originalisoth
maintained as h Iqbal publishby North Co ohne Di Manse mint to Records Retention and Schedule for ordered
ivmoh
o lbu enl which published Dpmeat ELlh oar Division PaHistorical li Reorder AdditionalRa n new be I xdfa �nin-
01.0 .ruin cowl liezt(1,nepai ell of L:by o nal and Natural Resor >,I030 h111 Serve Coder,[(olein,He D(991G32,(Condor52-
ol-c0)
MLN133961(Revised 4/03)
Enviwmmenlal Health Services Sacliou(Review 1fOo)
Pool Drain Safety(VCR)Compliance Do to Completed form must
PERMIT CANNOT RE ISSUER FORM IS INCOMPLETE be submitted with
A separate form is required tin each pumping system. application
Name of Pool A-dr:AA. ..-__ L skAhrel / 1'etA' Ic-o
Address_J(v4 _ /onovx.[_ _ 17 ha .R-_ L .%Ovi 1_ 11.1c_ f
FORM COMPLETION-A separate Pool Drain Safety Compliance Data form must he completed and submitted
for each individual pool at a facility inelndin2 spas,wading pools,and other pools.
I. Puma Flow �ll..,.. -a
Pump Manufacture) nenf'n.rnY-- Made]ll - pt710 _- -_ Horsepowerls—
Maximum Pump Flow. Maximum flow ratetim pump curve_ rt' t0 wpm. (Provide snppnrling evidence if flow reduction)
7. Drain Sump Measurements This is the arca under the.Mont drains,if field built sump may need to remove drain cover ram lime In nreasure_
(Check here ifsumpless_ Wen proceed to next section)
Sump slaps: Round-width: inches diameter', OR Square- _ Inches X /D inches
Su np minimum depth 7 inches Dinrncrer of outlet pipe in sump _� inches
Distance atop(inside)of outlet pipe from bottom of cover/grate7 _inches
Sump manufacturer mrd model tl rf,vailable_ A),/It Fr i lL BJ:I t-
3. Drain Cover/Grate Data
Number of drains on each pump .3 Distance between drains(ml centers)_LV
Cover/grate mnnvfacturcrkfaugyr ,model kadviltsvE to Lifespan:
Maxinuun flow rating of cover/grate_ ( gpm(floor); _- __ _gpm(wall)
Date drain cover/grates installed: y-12-It( EXPIRATION DA'Z'E, V-IZ-2013
4. Equalizer Covers
Number of ofterah/e skimmer equalizers 0 OR Have the equalizers been disabled') Y12/NO tart^:fer Ove—A.— Gu FFV
Equalizer fitting Manutheturer __. ,model _ ,Litespan _
Equalizer fitting maximum flow rating_
Dare equalizer cover/grates installed: EXPIIIATION DATE:
S. Safety Vacuum Release System(SVHS)-SVRS requlmd if dual drains we closer num 3 feet on center or pump has a single drain rvitr
bfuckablc cover or some.
Safely Vacuum Release System menu reignite
VReuam foe-Choose One
vacuum line in pool OR
Protective cover on vacuum fines installed belare May I,7010 OR
Self-elosing,sell-latching cover designed In he opened with a tool on vacuum lines installed after May I,2010
Pull name apeman providing this inlbnmdion C kr.S♦-opkte- Lys rye rosy/or
Sig,amre_ s<_cylip Dem t/-Z$--t`4
NCIH IS
Revised 1012016