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Home My WebLink AboutAdrian L Shuford Spa App 550014 05 01 18.tif f$5500' 4 N.C.Department of Environmental and Natural Resources { Li 0°YOtt- Division of Environmental Health APPLICATION FOR SWIMMING POOL OPERATION PERMIT POOL INFORMATION: Name of public swimming pool: Adr:avn. L. S.v Fora VAL Pt Sev% Street address of pool location: I) o'1 (ono ver Olvd E• City:County: ( ono ver __- Cato-w Go,_ Type of public swimming pool (check one) ❑ Swimming pool ❑ Wading pool Spa ❑ Other(describe) Date constructed or remodeled: (check one) ❑ Before May 1, 1993 lam May 1, 1993 or later Dates of operation: opening date 7 .r 1104 closing date BeC 31 Logy Hours of operation: opening time 5-boo ttm closing time Cl cc p OWNER INFORMATION: Name of owner: YMCA oe (alti -L Vrdley _ Mailing address: Il or{ Lon.over Diva E. ( onoverr {Vt. a.i(61 Contact person: kwrw. L tonlrgtr Telephone: UL,6 -44 y- 4,13e OPERATOR(On-Site Manager) INFORMATION: Name of pool operator: C 4 ricl-oo&er Yl Address: ILD' Lon.ev..r fittest IS lottpver WL 3-&&t3 Telephone number: 9LK - 4'13- v935- _ Pool operator trained by: (check one) � National Swimming Pool Foundation (Certificate Number: GPO —q C 77(c ❑ Other (please specify) APPLICATION SUBMITTED BY: Gqy� � � Owner or operator: �f"� (J6ostoplar To.)(kr Signature Typed or printed name Date: 4-y-100C Purpose General Statute I90A-282 rcgones the Commission Health Services to adopt mice governing public swimming pools.The rules in I5A NCAC I8A2500 require the owner or operator to apply annually for an operation permit for each public swimming pool.This form is to allow comers 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 roust 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 Department:which are published by North Carolina Division of Historical Resources.Reorder:Additional norms may be ordered from:Division of Environmental Health,Department of Environment and Natural Resources}1630 Mail Service Center,Raleigh,NC 27699-1632,(Courier 52- 0I-00) DENR 3961(Revised 4/03) Environmental health Services Section(Review 4/06) Completed form must 'it Pool Drain Safety(VCB)Compliance Data be submitted with PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE A separate lornt is required for each pumping system. application Name of Pool Shy-fend YMAA 5fw FrIfvatrby Sys ton. Address If 0`1 (orvevCi" __ 01-v. e. 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. 1. Pump Flow , Pump Manufacturer WA:Sfer Flow —. 300 Model tme,to•r Horsepower Maximum Pump Flaw. Maximum flow rate( IS8 cpm. (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 ifsumpless ,then proceed to next section) Sump shape:Round-width: inches diameter: OR Square- 1 inches X 1 inches Sump minimum depth'[r inches Diameter of outlet pipe in sump 3 _ inches Distance of top(inside)of outlet pipe from bottom of cover/grateq inches Sump manufacturer and model#if available A t +... Stat 3. Drain Cover/Grate Data Number of drains on each pump 2. Distance between drains(on centers) 73'r Cover/grate manufacturer_At ra Star .model RAJA11_It ,Lifespan. SYCtirS _.. Maximum flow rating of cover/grate la Li gpm(floor): _ gpm(wall) Date drain cover/grates installed: A pr:) 240 I r ___EXPIRATION DATE: APAl d od.0 4. Equalizer Covers Number of operable skimmer equalizers X OR Have the equalizers been disabled? YES/NO Equalizer fitting Manufacturer i flX __,model SPA }r° , Lifespan S yew'S Equalizer fitting maximum flow rating I yd. 6t' _ .. Date equalizer cover/grates installed: her ?Ons EXPIRATION DATE Apel 1-0)-4 5. Safety Vacuum Release System(SVRS1-SVRS required if dual drains arc closer than 3 feet on center or pump has a single drain with blockable cover or sump. Safety Vacuum Release System manufacturer-• Vacuum line-Choose One VSlo vacuum line in pool OR Protective cover on vacuum lines installed before May 1,2010 OR Self-closing,self-latching cover designed to he opened with a tool on vacuum lines installed alter May I,2010 Full name of person providing this information_ C_h ri st0 Pktr Lo)o.n, De- lot Signature _ Date `I'"j-101 S_ NCDHHS Revised 10/2016 Completed form must Pool Drain Safety(NCB)Compliance Data be submitted with PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLE'T'E 11 �/ V A separate form is required for each pumping system. application Name°f Pool�rv.. Vftrok YMLh 5P.ti Tel- SYCICr— Address ii0£t Conovee 131.4 E Cortvar NL_ 236(3 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. 2. Pu.-e5 I. Pump Flow Pump Manufacturer Pen fa.:r Model f y,.h,ZptLtie.+ We% Horsepower 3 Maximum Pump Plow. Maximum flow ratefrom pump curve: (c/ 0 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- 11. inches X Ie inches Sump minimum depth 9 c inches Diameter of outlet pipe in sump 3 _-inches Distance of top(inside)of outlet pipe from bottom of cover/grate __..inches Sump manufacturer and model*/if available 3. Drain Cover/Grate Data Number of drains on each pump 2— _Distance between drains(on centers) 73 di Cover/grate manufacturer Aim.. y}p.r ,model why 1A R II I ,Lifespan: S y co-/`Z_ Maximum flow rating of cover/grate 3 I gpm(floor); _ gpm(wall) Date drain cover/grates installed: /Veil _ 20/S- EXPIRATION DATE: /kK%I eLO20 4. Equalizer Covers Number of operable skimmer equalizers N/A 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- Vacuo"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 after May I,2010 Full name of person providing this information C-k rt hPA_1_ Lobar. req(P/ Signatures Date Cf-q-t f,_ NCD£IIIS Revised 10/2016