HomeMy WebLinkAboutHickory Foundation YMCA Kiddie Pool App 04 18 23 ENVIRONMENTAL HEALTH j i,
ick,*) Catawba County Government Center I i
Catawba county
25 Government Drive I P.O. Box 389 I Newton, NC il6S8
public health Phone: (828) 465-8270 I Fax: (828) 465-827,
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Email: EHAdmin@Catawb nuntyNC.gov 0
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Application for Public Swimming Pool Permit
Pool Inforntatiott (( M l
Name of peblic swimming pool: tT((,tio r r @u_rt A e (/(/'-+;art / C A
Street address: 70( /3T 571. N ki i f
City:_ }-ir C Keay State: N e--- ZIP: Z-$'%4 I
Tiro of public swimming pool ]Swimming pool 31Votrmg pool FiSpo nOther (descrlee} j i
Date Constructed or rem44ed1 ,Before May I, 1993 .Iter May I, 1993
Dates of operation: Opening date: Closing date: /0 -3/`2g Opening
Noses of operation: time: S 4 Closes time: % p✓J1. . '
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Owner Information ( 1
Name of owner. t C KOr �o.�d.PE'a�, y/j1CR Owner email: I C�•p ki $
Matting address: 76/ /ST Si N ti I '
Cit!', //ie Ko r State:NC ZIP: of g6 O (
Contact Person: i9 LAC- All n e Phone#: 2-g - 3-2 Y ,2 8a 8 f
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Operator(On-Site Manager)Information
Pool operator. ?i c,Z. AL/7-0 Phone#: ..2'C - .32q- 2- 5 ' i
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Street address: 7d r /5r _S "(di i
City: ft/GkD 1`.7 State:NC ZIP: 2-‘66 I i
Pool operator trained by: ONational Swimming Pool Foundation (Certificate#: (04 ' 66,6/8 I 1
Other(please specify) IAe Pall Pro ckssp r Cdafr,c. 1 CASES
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Applkatroli Submitted by: �� v��`� � D ❑Owner Un�°for
Signore of Applicant �• . iL�� Date: �'°�
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Depwtareatsf Enlnonnsten A Neteri Aesewees,163O Moe Sin ce Ca lor,A of eieb,IIC 17 A99.1632,(Cosier 52.01-00)
E0ENA396I tAsoised4/03) Eis roernrdal Health Servkrs Sidles(Pedro IJO6(
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Pool Drain Safety Compliance Data
PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE ; i r!
A separate form is required for each pump including circulation.jet or feature.
XI
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Name of Pool /JGnoty rJ and�a'` )'i7ICr9 ID# , • i 5 O e 6
(Fe04vrt ) fi 6F''I,c r2o49`'1 ((', ,.r ) Icy ;
1. Pump Flow a*' lci lorscpower -3
Pump Manufacturer_ ,J14 0,. 0;1 fat.E,o•� ) _Model II_ _ `
D i6yc 1
Maximum Pump Flow at highest speed FROM PUMP CURVE/ ♦ / g!„1r Pump use Circulation jet!feature(ca�cle one)
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Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES 0 •
Flow meter manufacturer l) A et dry Flow meter reading g-- GPM
n— 1 •
2. Drain Sump Measurements Is drain cover sumpless? YES/NO
OR: Field built sump(cire a if yes)
Sump manufacturer and model - I
Diameter of pipe entering sump /2 inches. Pipe enters through BOTTOM/Orof sump(Must circle one),! ! y;
Distance between highest point of outlet pipe and top edge of sump- /14 inches.Sump dimensions A.1/X .24, t
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3. Drain Cover Data-MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-Attach Instructions to fgrpn.
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Number of main drains on each pump 3 Distance between main drains(on centers) feet �Q
_
Cover/grate manufacturer Qg0�2 ,model j2yx �GBA approv t�2017(circle o )
Flow rating from instructions:((- fiyc- gPm Cover(s)located on pool eti wall(circle one)
1,2., {
Date installeda019 go ZL Lifespan "`yt ___,EXPIRATION DATE Ly 3
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4. Eaualizer Covers I
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Number of operable skimmer equalizers Have the equalizers been permanently disabled? NC)
Equalizer fitting Manufacturer_ -_ Model .l__. -- ifespan I i-- —
Bulkhead adaptor Manufacturer .Model —.Date installed
Cover is located on(circle where mounted):Floor/wall
Diameter of equalizer pipe I
Equalizer fitting maximum flow rating AN gpm.
Date equalizer cover/grates installed _EXPIRATION DATE:
5. ,Safety Vacuum Release System tSVRS)-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 r
Self-closing,self-latching cover designed to be opened with a tool on vacuum lines installed after May 1,2010 : 1
person ' j_t_ _ _Phone number: en- 3Z' -2(;e� .
Full name of providingthis information ---- - ----
03
11
Signature7i'‘--.-9- - -
Date '11)-
NCDHHS
Revised 4/1/2022 for immediate use.
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Instructions for Completion of the Pool Drain Safety Compliance Data Form
Please review the instructions below to ensure the Pool Drain Safety Compliance Data form is properly
completed and all required information required. All components must be approved and field verified by
the Health Department prior to the issuance of an operation permit in accordance with Rule.2539(c).
A FORM FOR EACH PUMPING SYSTEM MUST BE PROVIDED.
1. PUMP FLOW—Enter the maximum flow from the manufacturer's pump performance curve. For
variable speed pumps, enter the maximum flow at the highest speed. If a flow reduction is requested,
attach required documentation. A functioning flow meter will be required to permit a pool with a
flow reduction.
2. DRAIN SUMP MEASUREMENTS—Measurements are needed to determine the size of the
cover/grate and to assure the sump is deep and wide enough to meet the requirements in the
cover/grate manufacturer's specifications.
3. DRAIN COVER/GRATE DATA—Enter the manufacturer, model, lifespan expiration date and
maximum flow for the main drain cover(s). For VGBA 2017 covers,attach a copy of the flow rate
chart.
4. EQUALIZER COVERS—Enter the number of operable equalizer line covers,the manufacturer.
model, lifespan expiration date and maximum flow for the equalizer covers. Provide bulkhead adaptor
information. If all equalizer lines are disabled or pool has no equalizer lines, please provide details on
the form.
5. SAFETY VACUUM RELEASE SYSTEM(SVRS)—SVRS is required if dual drains are closer
than 3 feet on center or pump has a single drain with a blockable cover or blockable sump. Enter the
manufacturer of the safety vacuum release system (SVRS). SVRS must be tested according to
manufacturer's instructions,provide date of last test. If using other secondary method of'preventing
bather entrapment per Rule .2539(b), please attach documentation.
6. VACUUM LINE— If vacuum line ports are present in the pool, please indicate the type of cover(s)
on the form.
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.
The Health Department understands that the required information and/or measurements may be
beyond the scope of owners or operators.In those cases,it is recommended that you contact a
Registered Design Professional(Professional Engineer or Licensed Architect) or a knowledgeable
pool professional to assist you in completing the form.
NC DHHS
Revised 1/27/2022
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TechnicalSpecifications (3 HP Models) -- //N/ 033 a.o3 i2-366(45A
IZEEM;r7,1=MIVit 208-230 VAC Etii;th'Orintieltit1
NEMA Type 3/IPX5 .-. .ittiosiare ,•ETZE.171.7'u...TIMMIKO 12.4/11.2 Amps Rating
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Pump Dimensions (3 HP Models)
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INTELLIFLOY"VSF/INTELLIPRO3T"VSF Variable Speed and Flow Pump Installation and Maintenance Guide
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A CATAWBA COUNTY
�' C." 100A SOUTHWEST BLVD
` NEWTOPHONET828.65 83 qH A 28658 RECEIPT
U 111! Tuesday,April 18, 2023
18 4 2 sM www.catawbacountync.gov
PAYOR: YMCA OF Catawba Valley
YMCA OF Catawba Valley
PAYMENTS
TRANSACTION NUMBER: TRC-62160076-18-04-2023
PAYMENT DATE: 04/18/2023
PAYMENT TYPE: Check 84392
received in Hickory
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
04-23-421389 110-580200-663000 Pool Inspection Fee-Seasonal $150.00
TOTAL PAYMENTS: $150.00
FLI-0000182
CASE TYPE: Food&Lodging Institutions WORK CLASS: 51 -Seasonal Wading Pool
SITE ADDRESS: 701 1ST ST NW RD,HICKORY NC
Manager HICKORY FOUNDATION YMCA,701 1ST ST NW,HICKORY NC 28601
Paid By YMCA OF CATAWBA VALLEY,315 1ST AV NW SUITE 104,HICKORY NC 28601
B:8283249622
**NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator YMCA HICKORY FOUNDATION,701 1ST ST NW,HICKORY NC 28601
B:8283242858C:8285145512 PAULN@YMCACV.ORG
receipt 04/182023 15:11 Page 1 of 1