HomeMy WebLinkAboutSpa Athletic Club 530059 App 01 12 23 , t • ,, ii,..i.e.,„\--:-„;
F.NtARONIVIENTAL HEALTH
Vr Catawba County Government Center
CO F.4.'k.I. .:' 25 Government Drive I P.O. Box 389 I NeMon, NC 28658
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Phone: (828) 465-8270 I Fax (828) 465-8276
RECEIVED
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Application for Public Swimming Pool Permit
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vii 5,300kA C,
Name ofpublk swimming pool:_____,Lie . ./4111 /177/267776 6 449_ Environmental Health 5-
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Street address: . 9/) Z
City: ,464-xy , State': / - ZIP:
Type of public swimming poogwimming pool FlWadin ool 1- VI-101hr {describe)
Date constructed or remodeled:LiBefore May I 1993 itar May 1, 1993
Dates of operation: Opening date: Closing dote: ,54:72 //r"_.Opening
Hours of operation: time: ,,,,i"1 JIM Closing time: 4/7f27
f,',,,.,i,: ! -4.q.,.1•,.., ,,i,,,: p r
Name of owner: c '- •'''''' wner email: //.)
`',.—rM 976 7' X'aiie rjAtKr 69--(1,1,72-zemr44.4
Mailing address:_ , 9.&,/ Z 'jig 7 /I/
City: /(Verelf State:NC ZIP: o oav
Contact Person:
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Phone#:
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Pool operator: /11/177/Lri .6,'Zalki Phone#: X
Street address: ,Cdrfil7C
City: State:NC ZIP:
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Pool operator trained by: Notional Swimming Pool oundation (Certifitate :
Other lease spetifyI—' attoxit to .
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4-heog 56:- - 779-71-41-Afc
Applitation Submitted by:
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6- . 7257.&IA, I ' lOwner [_10perotor
_7 Signature of App -litant: Date: /672-7k-ze)
Purposa General Same 130A•782cequires ifi a tenunittion Health yervictsto adopt rul as governing publir swimming pooh,The rules In 15A NCAC 15A.2500 requiro the owner or operator to apply annually
for an operation permit far each public swimming pool.This form is to don ownors or operators of Odic swimming pooh N aptly far permiis.Preparation:The Information requested on this farm is ta bo
completed by the pool owner or A designated representalive(Ilk OWIRt.ille completed application is:submitted to the heat[mall department Inc tht MOAN Ai WO the public swimming pool to located.A
seporOlg application inust bo completed let each public swimming pool.Copies:Original to ha maintained at the fecal health department.Disposition:Please refer to Records R etentian ad Disposition
Stheclute far County/District Health Departments which are published by Nu/fit Carolina Division a!Historical Resources.its-Wert Additional F0111a ru ay be ordered from:Divilion of faifiraninentel balffi,
Deportment of Environment and Hamra!Resources,1A30 Mail Service Centor,lialeigts,NC 27894.1632,((cosier 52 01.001
....---
DM 3961(Rovtsed 4/0) Fnivitenenentiel hletOi Seniors Sentient(Rev:m.5/06)
Completed form lrnisit
+ Pool Drain Safety(VGB)Compliance Data
PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE be submitted with
A separate form is required for each pumping system. application
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,Address
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 e.) .`L �" 5';,/kdre2f)
14 gi91,
Pump Manufacturer f , • - , , ,, • Model#, J.- �"orsepocver
Maximum Pump Flow. Maximum flow rate Pon:pump curve: ,�' 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- / inches X inches
Sump minimum depth till inches Diameter of outlet pipe in sump inches
Distance of top(inside)of outlet pipe from bottom of cover/grate7
inches
Sump manufacturer and model#if available
3. Drain Cover/Grate Data e j /I
Number of drains on each pump Distance between drains(on centers)
Cover/grate manufacturers �1 model 1SL A6j,q.Li espan: „1":964j
OA
Maximum flow rating of cover/grate�}' Cj pm(floor); t,,� gpm(wall)
Date drain cover/grates installed: J/� / I , EXPIRATION DATE: I5Y / '
4. Equalizer Covers / e f
Number of operable skimmer equalizers OR Have the equalizers been disabled? Y �/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-
Vacuum line-Choose One
/o vacuum line in pool OR
+O Protective cover orvacuum lines installed before May 1,2010 OR
Sell-cllr ing,self-1 itchilng cover designed to be opened with a tool on vacuum lines installed after May 1,2010
Full name of per o rovi) information s in this � � `�� "
Signatur Date " ��,�
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NCDHHS y 7
Revised 102016 / . y .
/ e
CATAWBA COUNTY
I00A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
PHONE:828.465.8399
Thursday,January 12, 2023
8 4 2 5M www.catawbacountync.gov
PAYOR: SPA ATHLETIC CLUB
SPA ATHLETIC CLUB
PAYMENTS
TRANSACTION NUMBER: TRC-55307830-12-01-2023
PAYMENT DATE: 01/12/2023
PAYMENT TYPE: Check 13841
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
01-23-416833 110-580200-663000 Pool Inspection Fee-Year Round $200.00
TOTAL PAYMENTS: S200.00
FLI-0000186
CASE TYPE: Food&Lodging Institutions WORK CLASS: 53-Year-Round Swimming Pool
SITE ADDRESS: 920 2ND AV NW DR,HICKORY NC
Contact Person SPA ATHLETIC CLUB,920 2ND AVE NW,HICKORY NC 28601
C:8283285949
Establishment SPA ATHLETIC CLUB,920 2ND AV NW,HICKORY NC 28601
F:NONE NONE
**NO PEOPLESOFT ACCOUNT ASSIGNED**
Manager SPA FITNESS CENTER INC,920 2ND AV NW,HICKORY NC 28601
Pool Operator SPA ATHLETIC CLUB,920 2ND AVE NW,HICKORY NC 28601
C:8283285949
receipt 01/12/2023 13:54 Page 1 of 1