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Home My WebLink AboutAdrian L Shuford App 550014 02 07 23 ENVIRONMENTAL HEALTH - °e '94411�`f Catawba County Government Center c a t aw b a county 25 Government Drive I P.O. Box 389 ( Newton, NC 28658 public health Phone: (828) 465-8270 I Fax: (828)465-8276 M\NING.LIVING.BAIHHB. Email: EHAdministrativeAssistants@CatawbaCountyNC.gov Application for Public Swimming Pool Permit Pool Information f I.. 006 0)04 Name ofpublicswimmingpool: Shuford YMCA Whirlpool I F aD,$bSbD)Li- Street address: 1104 Conover Blvd E. City: Conover State: NC ZIP: 28613 Type of public swimming pool ❑Swimming pool ❑Wading pool [ Spa ❑Other (describe) Date constructed or remodeled:❑Before May I, 1993 ❑/After May 1, 1993 Dates of operation: Opening date:0 1/01/2023 Closing date: 12/3 1/2023 Opening Hours of operation: time: 5a Closing time: 9P Owner Information Name of owner: YMCA of Catawba Valley Owner email: logant@ymcacv.org Mailing address: 1104 Conover Blvd E. City: Conover State: NC ZIP: 28613 Contact Person: Logan Taylor Phone#: 828-493-0435 Operator(On-Site Manager)Information Pool operator: Logan Taylor Phone#: 828-493-0435 Street address: 1104 Conover Blvd E. City: Conover State:NC ZIP: 28613 Pool operator trained by: 58P9V7W National Swimming Pool Foundation(Certificate#: ) ❑Other(please specify) Application Submitted by:Logan Taylor ❑Owner [. .operator of Applicant: —Q�L ` el' Date: 2/6/2023 Purpose General Statute 130A-282 requires the Commission Health Services to adopt rules governing public swimming pools.The rules in 1 SA NCAC 1 SA.2500 require the owner or operator to apply annually for an operation permit for each public swimming pool.This form is to allow owners 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 m which the public swimming pool is located.A separate application must 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 Departments which are published by North Carolina Division of Historical Resources. Reorder.Additional Forms may be ordered horn:Division of Environmental Health, Department of Environment and Natural Resources,1630 Mail Service Center,Raleigh,NC 27699.1632,(Courier 52.01.00) DENR 3961(Revised 4/03) Environmental Health Services Section(Review 4/06) a. Pool Drain Safety Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE A separate form is required for each pump including circulation,jet or feature. Name of Pool 5 h,acAre4 '/h,C f Lv k T Iro't;I 1D# 1. Pump Flow Pump Manufacturer Pc..+Wi Model# J P1(—t Horsepower 3 Maximum Pump Flow at highest speed FROM PUMP CURVE: 1 S i( gpm. Pump use: ircula i /jet/feature(circle one) Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES/le Flow meter manufacturer give._ wi _ — k. t Flow meter reading It 0— 15 0 GPM 2. Drain Sump Measurements Is drain cover sumpless? YES/1RD) Sump manufacturer and model A vIA OR: Field built sump(circle if yes) Diameter of pipe entering sump 3 inches. Pipe enters through BOTTOM ACP of sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump V inches.Sump dimensions gXgi 3. Drain Cover Data—MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-p Attach Instructions to form. Number of main drains on each pump " " Distance between main drains(on centers) <p feet inches Cover/grate manufacturer kt.,,,A, . (a. - ,model ''AV—710;1/1 ,VGBA approval 2008/4E5(circle one) Flow rating from instructions:____AALi gpm Cover(s)located on pool:Floor/wall(circle one) Date installed 01//2 0 Lifespan s EXPIRATION DATE OW 2 3-- 4. Equalizer Covers Number of operable skimmer equalizers have the equalizers been permanently disabled? /NO ' Equalizer fitting Manufacturer ,Model ,Lifespan Bulkhead adaptor Manufacturer .Model ,Date Installed Diameter of equalizer pipe Cover is located on(circle where mounted):Floor/wall Equalizer fitting maximum flow rating gpm. Date equalizer cover/grates installed EXPIRATION DATE: 5. Safety Vacuum Release System(SVRS)—Safety Vacuum Release System manufacturer/model#- You will be required to demonstrate effectiveness during permitting inspection.Date last tested 6. Vacuusm Line Choose One / No vacuum line in pool OR Protective cover on vacuum lines installed before May 1,2010,OR Self-closing,self-latching cover designed to be opened with a tool on vacuum lines installed after May 1,2010 Full name of person providing this information kfiret — Leone number: t 2(—L/93—0°/1.f Signature ��/ .. Date 2—4-2 3 NCDHHS Revised 4/1/2022 for immediate use. • Pool Drain Safety Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE A separate form is required for each pump including circulation,jet or feature. Name of Pool 5 hr. Wt4 //4 C 11- I.. kir/ Pop/ Ter) ID# 1. Pump Flow Pump Manufacturer pe A a) Model# L✓Pk_g Horsepower 3 Maximum Pump Flow at highest speed FROM PUMP CURVE: I tip gpm. Pump use:Circulation/6/feature(circle one) Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES/151 Flow meter manufacturer WA. Flow meter reading GPM 2. Drain Sump Measurements Is drain cover sumpless? YES/NO Sump manufacturer and model 41.,✓ct. S1 ..,— OR: Field built sump(circle if yes) • Diameter of pipe entering sump 3 inches. Pipe enters through BO'CI'OM 1 of sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump y/- ` inches.Sump dimensions - 3. Drain Cover Data—MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-!Attach Instructions to form. Number of main drains on each pump Distance between main drains(on centers) tD feet inches Cover/grate manufacturer AI, ,$ ,model V/AV—)d'1/f ,VGBA approval 2008/4r -i(circle one) Flow rating from instructions: ac, gpm Cover(s)located on pool C, 4151(circle one) Date installed O'//2 0 Lifespan EXPIRATION DATE O'//2 S- 4. Equalizer Covers Number of operable skimmer equalizers p Have the equalizers been permanently disabled? YES/NO Equalizer fitting Manufacturer ,Model ,Lifespan Bulkhead adaptor Manufacturer .Model ,Date Installed Diameter of equalizer pipe _ Cover is located on(circle where mounted):Floor/wall Equalizer fitting maximum flow rating gpm. Date equalizer cover/grates installed EXPIRATION DATE: 5. Safety Vacuum Release System(SVRS)—Safety Vacuum Release System manufacturer/model#- You will be required to demonstrate effectiveness during permitting inspection.Date last tested 6. Vacuum 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 1,2010 Full name of person providing this information Chri.5f7)pAtr- IA?4Phone number: `I ?—O'1 b.-- Signature ""1-7" Date 2`-(0—2. 3 NCDHHS Revised 4/1/2022 for immediate use. $A �� CATAWBA COUNTY t;i7i.. 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT PHONE.828.465.8399 L) �' 7 Tuesday,February 7,2023 18 42 5M www.catawbacountync.gov PAYOR: YMCA OF CATAWBA VALLEY YMCA OF CATAWBA VALLEY(Taylor,Logan) PAYMENTS TRANSACTION NUMBER: TRC-57165430-07-02-2023 • PAYMENT DATE: 02/07/2023 PAYMENT TYPE: Credit Card 300855385 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 02-23-417966 110-580200-663000 Pool Inspection Fee-Year Round $200.00 TOTAL PAYMENTS: $200.00 FLI-0000204 CASE TYPE: Food&Lodging Institutions WORK CLASS: 55-Year-Round Spa SITE ADDRESS: 1104 CONOVER BLVD E,CONOVER NC Owner YMCA OF CATAWBA VALLEY, 1104 CONOVER BLVD E,CONOVER NC 28613 B:828-464-6130C:8284930435 **NO PEOPLESOFT ACCOUNT ASSIGNED** Pool Operator LOGAN TAYLOR,5525 BRIDGEWATER DR,GRANITE FALLS NC 28630 C:8284930435 receipt 02/07/2023 14:44 Page 1 of 1