HomeMy WebLinkAboutLake Hickory Country Club App 500022 05 01 18.tif N.C- Department of Environmental and Natural Resources < 0 q5t�V��1 �
Division of Environmental LLcslth (I-1, WI° J
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APPLICATION FOR SWIMMING POOL OPERATION PERMIT
POOL INFORMATION:
Name of public swimming pool: , 4 e " l+u ewet: ---ra1a
Street address of pool location: e) �/ '�.- 4,14y) - �G �e -City: County: 1 cg — -� ':a - (._) a) /k
}'pe of public swimming pool (check one) [. Swimming pool
LI Wading pool
❑ Spa
❑ Other /describe)
Date constructed or remodeled: (check one) Before May I, 1993
❑
May L1993 or lat
�v�
Dates of operation: opening date co_ losing data ._>£,rt
flours of operation: opening time /a 9.0 Ger closing time 8 Pyr
OWNER INFORMATION: //
Name of owner. L ,4' /r,�Odi.Y 2 Ciq y'9
Mailing address: p ✓'^."• (// (?(; __)4et_a[/ 41(
Contacd person: ��t .�, _t Telephonic: - WS-0 ' o%-5 jo
OPERATOR(On-Site Manager) INFORMATION:
Name ofpool operator � , 11-
Address: �'i . a R �n .1-.0 y*lr //."._ •Telephone number: e",31J f -- --.
Pool operator trained by: (check one) ❑ National Swimming Pool Foundation
(Cortilleale Number_
la7 Other Orldacc s/eci1 ) „,f //t
APPLICATION SUBMITTED BY:
Owner or operator: r_�i f ❑ - � ,.1f w . K„ 4 ry
$ygnaanure ./1 Typed orprktived name
Date:
Pupate datheral thatutcEH) -2b2 2throres rho Conatertior Health that adopt P pubbe strumthith paths.Tlo ;m 15A
NtAC ISA.250C recthro tits owner CIF operator to awl. annually't ar operator]permit for pubic swilthningp I IIs for.n a,to allow.
owners :operators or public ratingpoots to epi ly for tis I-Ord:add:onl'hc SOMULLIOn remorsteau this s to be eompl -ed by the
pool owner or a designated represcatatne olthe Lki[D]lkla!appItt aboncreel toInc local der:th department for the tantyln
which the moil strantnirtg pool is iocatht. rep:rata appl.cat[00matt he completed for hyo avomming pool Copies'. Ortgthal to be
maim-rood at the local hneltbdepartment R9poaa Ir:ease,CeaRecords
Rethation
-d and sporitton Sahedthe [0Cmeed .
nra-nenr I paddled 1 North CronU [:Isere e ne_s. RAo1 A[ Poem o. trout Flit
Of R mnm .l Helu,Dept Intent iFtr..rn.edb.ur.. sso . ION Moil cc ( caor. ioeig Ni:r i99-l6nH,(Homier c -
v ,)m
UF_NI2 3%1([2easea 4/03)
Envarnmeatal Health a 3vmes detthon(Review-I tnti
:S(le?' grKkr s �� 6/n1-1/,�� -
Pool Drain Safety(VGD)Compliance Data Completed form must
PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE he submitted with
A separate form is required for each pumping system. application
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NameofPool R/C r�__L//GCOo'y C G ft " i �V , k - -
Y9 7 I� p 1
Address / ?(� / zG [ �Mi bC/ /.r "R -- Y r `C, i
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
Pump Manufacturerh mgPADip Model t LaL I lorscpntccr /6
Maximum Punlp Pimv. Maximum low rat murkc c ��� spin. (Provide supporting evidence ifllow 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 scginti
Sump shape: Round-width. inches diameter: OR Square- I5 inches X I7_inches
Sump minimum depth inches Demeter Dfoudett s c -inches
I P �1/_... pipem sump
Distance of top(inside)of outlet pipe From bottom of cover/gram /2-#) inches
Sump manufacturer and model I if nvai lnhle
S. Drain Cover/Grate Data o t
NumberId m oneach pump
�2-- Distance betweendrains(.n centers) �
Cover/oratenmuliactu- r7 /C✓✓/i$/4/ model /1b/ /✓l -% z t fl pan, y,ec . e •• " - 1. Ii'
Maximums flow rating ofcover/grate 11Y" gpm Moor): _ gpm(wall)
Date drain cover/grates installed: .a -i EXPIRATION DATE: r2 U 1 rp
1. Equalizer Covers
Number oroerable skimmer equalizers /j/O4' OR I(ave the equalizers a disabled? ES NO
fi
Equalizer fitting Manufacturer model _ ,I it spuq_ 0/
Equalizer fitting maximum flow rating
Dale equalizer covcdgratos installed: EXPIRATION DATE:
i. Safety Vacuum Release System (SCRS)—S VItS requ i red ifdual/Indus lac closer Ilio 3 feet on center or pump has a single drain with
block able cover or sump.
Safety Vacuum Release System manulacmmr-
Vacuum line-Choose One
No vacuum line in pool OR
_F./Protective cover on vacuum lines installed before May L 2010 OR
Self-closing,seFIlatching cover designed to he opened with a mol on vacuum lines installed alter May I.2010
T�� ✓✓ s
Pull nameofp nproviding ll iyncur nettan .-1�Y' C��� _— q VIA _ __
Signature .%.( ! Ceti
D,vc / ;*✓c
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NCDltIIS
Revised I01201