HomeMy WebLinkAboutLa Madeleine App 500041 05 11 23 �1 ENVIRONMENTAL HEALTH
NNW Catawba County Government Center
catawba county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
public health Phone: (828) 465-8270 I Fax: (828) 465-8276
M/KING.IIYING- 1E1111.
Email: EHAdmin@CatawbaCountyNC.gov
Application for Public Swimming Pool P rihit
Pool Information
J�oot� 6000 Li f
Name of public swimming pool: La. 1aA t rrl!C t4 41 r T
Street address: ( 0 0 ( (-I 4.r f ve N l !I
City: Hie_kb Stater"C--- ZIP: -,�(00i
Type of public swimming pool IESwimming pool ❑Wading pool []Spa []Other (describe)
Date constructed or remodeled:ngefore May I, 1993 []After May I, 1993 �I
Dates of operation: Opening date: S-�o 2n� 1�Closing date: AI-2o23 Opening
Hours of operation: time; o NO dosing time: (0`o I ni
Owner Information
Name of owner: Le,010-At_ 1-Vbm 0W(14i A.5o C;I± Owner email: 6.vL0Shot4 (c) (hvvnfti,w 1
Mailing address: 100 S At 5( A.Ve_ N L
City: 1'ki cv_ora, State:NC ZIP: `A3 601
Contad Person: RL: 0 9% Phone#• Z 3— —�l`k i
Operator(On-Site Manager)Information
Pool operator: ct h to 1°"u.L i<ni Phone#• $Z 8' 3 l O S 1 l l
Street address: Lk 4l (7-lUk fLn Vt-AK4ki. D f�
City: \-4., Lk .c Cz) State:NC ZIP: aE602--
Pool operator trained by: Ofational Swimming Pool Foundation (Certificate#:
❑other(please specify)
Application Submitted by: AA Lt Q d� �ns [2rOwner []Operator
flu n . .ts ' 0_ 2°z 3
Signature of Applicant: �?�(.c Date: I �
Purpose General Statute130A•282regaires the Commission Health Servicestoadoptralesgoverningpublicswimmingpools.Thervlesin 1SA NCAC ISA.2500require the owner er operator to apply annually
for an operation pennit for each public swimming pool.This Penn is to akw owners or operators of pudic swimming mob to apply for pernitr.Preparation:The information requested on this form is to be
completed by the pool owner or a desipmled representative of the owner.The completed appimtlon is admitted to the local health department for the county it which the public swimming pool is located.A
separate application must be completed for each pubic swimming pool Copies:Original to be maintained at the local health department.Disposition:Please refer to Records Retention and Disposition
Schedule For County/District Has Departaunt which are published by Writ Carolina Division of Historical Resources. Reorder.Additional Forms maybe ordered from:Division of Environmental Health,
Department of End renmeotand Nonni Resources,1630 Mail Service Center,Raleigh,NC 27699.1632,(Courier 52.01.00)
D EN R 396I(Revised4/03) Emkanmewal 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 6- rn a-C t Ile u2.- ID#
I. Pump Flow, ll
Pump Manufacturer ( J O Model# � ? -r!Sr)( 9,®Horsepower
Maximum Pump Flow at highest speed FROM PUMP CURVE: gpm. Pump use:Circulation/jet/feature(circle one)
Has pump been serviced(disconnected from power for
any reason)or changed out in last 12 months? YE�'�,�IOJ
Flow meter manufacturer glut LJL .1.AA 051-11`tg Flow meter reading 140 GPM
2. Drain Sump Measurements Is drainI0
i cover sumpless? YES/
Sump manufacturer and model ttay�.-�c.a�. OR: Field built sump(circle if yes)
Diameter of pipe entering sump I/ S inches. Pipe enters through BOTTO ID:of sump(Must circle one) �
Distance between highest point of outlet pipe and top edge of sump inches.Sump dimensions (f/l(/+ g
3. Drain Cover Data—MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-Attach Instructions to form.
Number of main drains on each pump a Distance between main drains(on centers) feet inches
Cover/grate manufacturer tAsO) ,model N 1,X!o'4 g 6 ,VGBA approval 2008/2017(circle one)
Flow rating from instructions: 10V gpm Cover(s)located on pool:Floor/wall j(circle one)
Date installed ' —4— `�Gifespan EXPIRATION DATE '6.— r `.q
4. Equalizer Covers
Number of operable skimmer equalizers Gil Have the equalizers been permanently disabled? YES/NO
Equalizer fitting Manufacturer A /Ar- ___,Model ,Lifespan
Bulkhead adaptor Manufacturer fu"/A4 . Model ,Date Installed
Diameter of equalizer pipe /v//AAtrr Cover is located on(circle where mounted):Floor/wall
Equalizer fitting maximum flow rating 'Y/4 gpm.
Date equalizer cover/grates installed Al/A— _ EXPIRATION DATE:
5. Safety Vacuum Release System(SVRSI—Safety Vacuum Release System manufacturer/model#- jVla
You will be required to demonstrate effectiveness during permitting inspection. Date last tested
6. Vac Line Choose One
uuLNo 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 pIA-41.Yu J 1I n.I•)U Phone number: VA- .310-51
Signature Date
NCDHHS
Revised 4/1/2022 for immediate use.
�4'A •• CATAWBA COUNTY
�' �}+ 100A SOUTHWEST BLVD
�' ` t�,,3 NEWTON,NORTH CAROLINA 28658 RECEIPT
,� PHONE:828.465.8399
Thursday,May 11,2023
/842 SM www.catawbacountync.gov
PAYOR: La Madeleine Homeowners Assoc
La Madeleine Homeowners Assoc
PAYMENTS
TRANSACTION NUMBER: TRC-63820024-11-05-2023
PAYMENT DATE: 05/11/2023
PAYMENT TYPE: Check 1674
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-23-422493 110-580200-663000 Pool Inspection Fee- Seasonal S150.00
TOTAL PAYMENTS: $150.00
'FLI-0000099
CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool
SITE ADDRESS: 1001 21ST AV NE,HICKORY NC
Applicant LA MADELEINE HOMEOWNERS ASSOC, 1005 21 STAVE NE,HICKORY NC 28601
**NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator JOHN PAUL KNIGHT,4418 GRANFLORAL DR,I IICKORY NC 28602
C:8283105111
receipt 05/11/2023 13:08 Page 1 of 1