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Home My WebLink AboutAdrian Shuford Splash Pad App 560001 02 07 23 L--� ENVIRONMENTAL HEALTH Catawba County Government Center c a t aw b a county 25 Government Drive I P.O. Box 389 I Newton, NC 28658 public health Phone: (828) 465.8270 ( Fax: (828) 465-8276 M.NING.LIVING.B[IBhM. Email: EHAdministrativeAssistants@CatawbaCountyNC.gov Application for Public Swimming Pool Permit �7 Pool Information 1 -DI--�'r^D �1�S Name of public swimming pool: Shuford YMCA Splash Pad ID206.V.A9tool Street address: 1104 Conover Blvd E. City: Conover State: NC ZIP: 28613 Type of public swimming pool ❑Swimming pool ❑Wading pool ❑Spa 110ther (describe) S,/wS&_ P4.4 Dote constructed or remodeled:❑Before May I, 1993 Duffer May 1, 1993 Dates of operation: Opening date-05/01/2023 Closing date: 10/30/2023 Opening Hours of operation: time: 8a 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: Dtfaiiiiiial Swimming Pool Foundation(Certificate#: 58 P9V7 W [Other(please specify) Application Submitted by:Logan Taylor riOwner erator Signature of Applicant: / " , _ ' �" Date: 2/6/2023 PurposeGeneral Statute 130A-282 requires the Commission Health Servicesto adapt rules governing public swimming pools.The rules in 15A 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 pooh 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 bad health department for the county in which the public swimming pool is located.A separate application must be completed for each public swimming pool.Copies:Origimd 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 from: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) 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 v rrl Y/411,L I- Se/A 5i.. AEI ID# 1. Pump Flow Pump Manufacturer Pith...'r Model it w p/( LI Horsepower 1 Maximum Pump Flow at highest speed FROM PUMP CURVE: 10 gpm. Pump use: iniZak, /jet/feature(circle one) Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES/.1'2 Flow meter manufacturer Yid Lv 611... Flow meter reading 7a GPM 2. Drain Sump Measurements Is drain cover sumpless? Ye/NO Sump manufacturer and model OR: 4 t ip(circle if yes) Diameter of pipe entering sump inches. Pipe enters through BOTTOM/SIDE of sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump 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 I Distance between main drains(on centers) feet inches Cover/grate manufacturer V OP4tX ,model ,VGBA approval 2008/2017(circle one) Flow rating from instructions: gpm Cover(s)located on pool:1pr/wall(circle one) Zero" 'ot!aetA.. Qv.+P eve4 rosi of l'n*cr. A Date installed Lifespan EXPIRATION DATE 47 4. Equalizer Covers Number of operable skimmer equalizers ee 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. Vacuup 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 I,2010 Full name of person providing this information e, j dam.Tly4,--Phone number: gz i(—*13-01./3 Y Signature Date e7 - av 2 3 NCDHHS Revised 4/1/2022 for immediate use. r i.r 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{t a c > 1'1 I A- SekaSh As.4 Pe...}vi'-L Ill# 1. Pump Flow Pump Manufacturer QGwia.+ - Model# ace k- 7r-0 Horsepower 7 s` Maximum Pump Flow at highest speed FROM PUMP CURVE: St{0 gpm. Pump use:Circulation/jet/fte a(circle one) Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES/_1P ) Flow meter manufacturer AOC. - ki i,. t-•C_ Flow meter reading 30o GPM 2. Drain Sump Measurements Is drain cover sumpless? YO/NO • Sump manufacturer and model (/or 17t,y OR: Field built sump(circle if yes) Diameter of pipe entering sump $ inches. Pipe enters through IM/SIDE of sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump 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) feet inches Cover/grate manufacturer V arit ,model ,VGBA approval 2008/2017(circle one) Flow rating from instructions: gpm Cover(s)located on pool:Floor/wall(circle one) Date installed Lifespan I i� . EXPIRATION DATE 4. Equalizer Covers Number of operable skimmer equalizers tat--- Il.ave 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 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 (r,,n3/Dy i f t-dle,..,7-4/ rrPhone number: t 24— Ye/3—dK3 Signature %-.A.,...1....., Date OZ o6-23 NCDIII IS Revised 4/1/2022 for immediate use. y14'A \ CATAWBA COUNTY 100A SOUTHWEST BLVD NEWTON,NORTH CAROLINA 28658 RECEIPT PHONE:828.465.8399 V ® Tuesday,February 7,2023 1842 5M www.catawbacountync.gov PAYOR: YMCA of Catawba Valley YMCA of Catawba Valley(Taylor,Logan) PAYMENTS TRANSACTION NUMBER: TRC-57165428-07-02-2023 PAYMENT DATE: 02/07/2023 PAYMENT TYPE: Credit Card 300855385 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 02-23-417963 110-580200-663000 Pool Inspection Fee-Seasonal $150.00 TOTAL PAYMENTS: $150.00 FLI-04-2017-084168 CASE TYPE: Food&Lodging Institutions WORK CLASS: 56-Seasonal Specialized Water Re SITE ADDRESS: 1104 CONOVER BLVD E,CONOVER NC 28613 Owner YMCA OF CATAWBA VALLEY,1104 CONOVER BLVD E,CONOVER NC 28613 B:8284646130C:2824930435 **NO PEOPLESOFT ACCOUNT ASSIGNED** Pool Operator LOGAN TAYLOR,5525 BRIDGEWATER DR,GRANITE FALLS NC 28630 C:8284930435 receipt 02/07/2023 14:42 Page 1 of 1