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HomeMy WebLinkAboutLake Hickory Country Club Splash Pad 560002 05 01 18.tif N.C. Department of Environmental and Natural Resources `,C7) JLQQ Qo< Division of Luvironnrental l lealth {- L1 " O&- ROIr] 5,234 APPLICATION FOR SWIMMING POOL OPERATION PERMIT �u `f POOL INFORMATION: tine of s public swiming pool AA/F M6.k0.r CU ¢ we , ��2I 5 location: 5/30 /�' Street j/ //et/ — —. City: County: /'4cL c, /a rU4d 4 f _ 'Type of public svinuning pool (el eck one) CI Swimming pool LJ Wali ng pool ❑ Spa Other //c :rfbc) Ss9 �tS k pocie IJate constructed or remodeled: (check one) ❑ Heroic May I, 1993 May I, 1993 or later Dates of operation: opening dale 1/4 t/ ,2 closing date Flouts ofoperation: opening lane closing time Z OWNER INFORMATION: Name of owner: / 772 Mailing address: (-) '0 LoyI CI ?.69 iL E-L{ d`` /UL Contact prion: —A f (ter, � F' v r ti Telephone: f - OPERATOR (On-She.Manager)INFORMATION: Name of pool operator. 12 ( _-` >- I to Address: Telephone number: , , Pool operator trained by: (cheek onej I I National Swimming Pool Foundation (Certilicate Number: tech-- Other(please specify) ,/1"7 C/1-- APPLICATION e AP'PLICITION SUBMITTED BY: // //'' Owner or operator: h-r ri f..p,(. e : _ -Jr1=r1.( ,j Get,. latae. '/(y>ed or printed name Date: /—�,;�_/ tr P se (41001111 Statute 130"\-282 thu CommissionI I .n Gra ice,to adopt itilus I }.I ilia mks in ISA sew INA 2ap0 impale the niv operatut to appiii annually fie eon permit roallroe '. : ,pool This ren- s towmi, rap spebi, i a I ca Ls .apple , pe ..Yep; fhcnlb:ra regcsed rf, Ic cmnp]C1ml by the pool 10111 ul dasignatad rupreacntatneof the IIlc Mill:Yelli 11 t b Y9 to ttie local haltI ilapaitmunt for the my in which do public swimmtnu pool is locoed A c1v e application 1111101 completed fn-each puha tv miming1 Copies: On - al to be maintained at the cal health capartineut Dap vrn Please-cru to R d;Retention mai D o .n SubmiuleIo County/District lleil;lr Dopa.nenls which are published by Northt'utoluitiD of.l➢.olc.l le,otcc.ReorderU(111101101 Forms mai,he tR_2i En .:Division llinvronmctal Health,Dcuai Puma tiChni.imminent I .2l Rmouream I .r Mail Nor Center. N( 6te-IGr3,(t iotti ler 51- 01-(101 DHNR 3961(Fevised 4/113) fm em.e.eculal health Scnaces Sx-i,n(Review.100 Completed form must Pool Drain.Safety(VCR)Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE he submitted with A separate form is required for oath pumping system. application Name(if Pool a' i /G flex 6 U . • is r .IV - 7-12 Address z/39// et-s/ --___fJ'iC.ii.K.y_ /[/G e4.04sa_ FORM COMPLETION—A separate Pool Drain Safety Compliance Data form must be completed and submitted for each individual pont at a facility including spas,wading pools,and other pools. I. Pump Flow (OfN��I IC 21-1/1221 nisi i sic"- /;/- I - 172a JiS Pump Yam jacinth'PENT¢ti c D ithr Model ;ISF —( - -0.A_ I In,sepower 2/, 00___.- Maximum Pump floss. Maximum how rate Rrom Pang)Ci a Te.-- pn_ (bode supporting c‘idence if floss«duction) 2 Drain Sumo Measurements This is the area under the floor drains.it fell built sump may need to remove drain cover one time to measure. (Check here if sumples .then emceed to next section) /S // // Swap shape: width: inchs diameter: OR Square- inches N _ infSes z Sump minimum depth /� inches Diameter of outlet p pe in sump Y inches Distance of top(inside)of culler pipe from hoeunt of cover/pude � N inches Sump main lacfurer anti model A if available 3. Drain(o /Grate Data Numher of drain:on each pump 1_ Distance between 1 a ins On cent -(/ / ,. , Lover/goneLover/gone ,manufacturer model I Fesparc VR__ Maximum flow rating of one'/gate _wpm(floor). gpm(wally) Date drain cosmigrates installed. "V 2 /-S __ EXPIRATION DATE: f��/ a. Equalizer Covers � Number ci�skiinn er /� equalizers�6 OR !love the equ al imrs been disabled? YES/NO Equal ter tithing Manufactt to ,model ,Lifespan_ E.quelizer fitting nrecimm11l flow reline Date equalizer covergales installed: EXPIRATION DATE: S. Safety Vacuum Release System(SVRS) SVRSI equ i and if dual Main,ate closer tom,3 fuel on center or pomp has a single drain with hlockahle other or sunip. Safety Vacuum Release System manuMen ver- Vacuum line-Choose.O44c No vacuumlin pool OR Protective cover on vacuum lint i Tilled d be4,rc May I-201(1 OR Sc If-closing.self-latching cover designed to he opened with a ton]on vacuum lines installed l alter May 1.2010 Full name of person providing this inlonnatot tac W 1111?_ _ i lv ,_ _ signature . -- . • 't;:- Rd 7,/,../ D� c �p) r� - NCDIIIIS Revised 102016 o W I-1 N - 9 9 •• n P P P 0 r eat ffi� [sr a re W'. • !, . I _ 4 " N �F 'P S N a � a (J S P P ,� P 01,E ( - --'o 9 F ; I 4 I e �o3 ; 3 594, / '= g /fnaa 3 - -- - © . II a F çN!I: ! ♦ i