HomeMy WebLinkAboutConover Swim Club App 500021 05 11 23 • ENVIRONMENTAL HEALTH
'' Catawba County Government Center
catawba county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
publi • hrP,illh Phone: (828) 465-8270 I Fax: (828) 465-8276
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Email: EHAdmin@CatawbaCountyNC.gov
Application for Public Swimming Pool Permit
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Pool Information ` rle....„..,,) ,-- „kg .
( `•) `) !`g5t:L�� ) 1
Name of public swimming pool: (leNV VW A) I PMl07 r o-fA
Street address: c ; I - 5 I"/& � I�YJ NO \f l f J__. .D--6.'LS
City: State: ZIP:
Type of public swimming pool I .Swimming pool nWading pool nSpa n0ther (describe}
Date constructed or remodeled:J.gefore May I, 1993 'After May 1, 1993 )
Dates operation: 6)a0)2�a-3 Closingdate: }O ( ) f?t)O--3 Opening ate, of 0pcni^g date:
Hours of operation: time: )b /l Closing time: 1 0 P1
Owner Information
Name of owner: (_-DO ( t 1 HF'1 I11/4,1ei6 C• Owner email: CO� SOI r�r�C C,1tili-,�1
Mailing address: P-a ED) , a74-
City: CO)JO kie--- State:NC ZIP: �(-4" )--
Contact Person: t"1 l 1_ 0 60`/ --E-- Phone#: 'SA , 3 I°• )(� 6--,
Operator(On-Site Manager) Information Pool operator: 141 i 4 — CADY( �Q- Phone#: D X • 310 . /(fl
Street address:
City: State: NC ZIP:
Pool operator trained by: [ tational Swimming Pool Foundation (Certificate#: Q`-`1 --ra3 - -70 }
nOther (please specify)
Application Submitted by: h )Y-r✓ l - Owner Operator
Signature of Applicant: //��! Date: l 7/z 3
6 /
Purpose General Stir tute130A-282 requ ires tfie Commission Health Services to adoptrul es governing public swimming pools.The rulesin 15A NCAC I SA.2500 require the owner or operator to apply annually
for an operation permit for each public swimming pool.This form is to slow owners or operators of public swimming pooh to apply for permits.Preparation:The information requested on this form is to be
competed by the pool owner or a designated representative of the owner.The completed appiaion is submitted to the lord health deportment for the county in which the public swimming pool is located.A
separate application oust be completed for each pubic swimming pool Copies:Original to be maintained at the local heaps department.Disposition:Please retails Records Retention and Disposition
Schedule for County/District Health Deportment which are pubished br North Carolina Division of Historical Resources. Reorder:Additional Forms may be ordered from:Division of Environmental Health,
Departmental Environment and Hound Resources,1630 Mail Service Center,Raleigh,NC 27699.1632,(Courier52-01.00)
DENR 3961(Revised4/03) Environmental Health Services Section{Review4/06)
•
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 ( tM �UG>j ' ITI
1 i� ID#
1. Pump Flow ,1
Pump Manufacturer Model#_-�--EP- vDD I iorsepower )(�
Z5°9> "` (o1 b • , ti -a 50 4 Ph
Maximum Pump Flow at highest speed FROM PUMP C VE:-gpm. Pump us:aMED/jet/feature(circle one)
Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES/agi 0 1*v"JS
Po 22 1h,.
Flow meter manufacturer Flow meter reading GPM WI �'b� , '
2. Drain Sump Measurements Is drain cover sumpless? YE`dd / u a-^,—-e,11.1-t
SPSP
Sump manufacturer and model O ' Field built sump(circl if yes)
Diameter of pipe entering sump 4' inches. Pipe enters through BOTTOM SIDE o sump(Must circle one)
Distance between highest point of outlet pipe and top edge of sump 8 inches. Sump dimensions I'
3. Drain Cover Data—MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-Attach Instructions to form.
Number of main drains on each pump 1 Distance between main drains(on centers) K`\—" feet inches
Cover/grate manufacturer GBA approval 2008 2017 ircle one)
4 M
Flow rating from instructions: 51 S s)located on pool: loor/wall circle one)
Date installed 44 t I �a'� LifespanS EXPIRATION DATE �1-J i 200-
4. Equalizer Covers 1 N j�
Number of operable skimmer equalizers /`r 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#-\P AS 3.0r0.S )1 c.
You will be required to demonstrate effectiveness during permitting inspection.Date last tested
Ay_do Jo gar
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 co r designed to he opened with a tool on vacuum lines installed after May 1,2010
i
Full name of person providin is in rmation I Phone number: weg's iO " J6o
..._
Signature Date �� /Q _ea 3
NCDHI-IS
Revised 4/1/2022 for immediate use.
Instructions for Completion of the Pool Drain Safety Compliance Data Dorm
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
lIA flMAR D ISWGio32HF2COC Rev A
K1:0CERTIFICATION OF COMPLIANCE
Contains: WG1o32BHF2 Description: 12"X 12" Suction Outlet Cover
Ratings: Are Shown in the Table Below. Open Area:_4s.o7sq-In_
Certified to Comply with Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety Act
codified at 16 CFR part 1450. Initial Certification May 2011.
Manufactured: After November 1, 2020, by Division of Hayward Industries, Inc. at K4-A, 214028
Block K4-A, Export Processing Zone Wuxi New District Jiangsu Province PRC 214028, China.
Certified by Hayward Industries Inc. 40o Connell Drive, Suite 6ioo, Berkeley Heights, NJ o7922,
Phone 908-355-7995 Contact at www.hayward-pool.com
Record Custodian is Customer Service at www.hayward-pool.com.
Email: https://www.hayward-pool.com/shop/en/pools/contactForin
Hayward Pool Products P.O. Box 51oo Clemmons, NC 27012-5100, Phone: 908-355-7995
To our customers,the Serial Number is a 17 digit number,preceded by letters"SN"
The Serial#Code: 21121005456789001
•First 2 digits are"21",conforming to UCC-128 symbology,signifying a serial#
•The 3rd—4th digits are the manufacturing"plant"code(12 for Clemmons,21 for Wuxi,China)
•The 5th—8th are"year&month"of the date of manufacture and assembly
•The 9th—17th are"unique serialized number"for each product
Tested to APSP 16 2017 per Section 1404 of the Virginia Graeme Baker Act (VGB) Pool & Spa Safety
Act. Tested by IAPMO, 5001 E. Philadelphia Street, Ontario, CA 91761 (909)- 472-41o° in August
2020. Certificate at: http://pld.iapmo.org/file_info.asp?file_no=0006353
Date of Installation:
Suction outlet components have a finite life,the cover/grate should be inspected frequently and replaced at
least every 7 years or if found to be damaged, broken, cracked, missing, or not securely attached. All other
components must be replaced at least every 28 years or if found to be damaged, broken, or cracked. The
screws must be replaced every time a cover is replaced.
Hayward Pool Products acknowledges that it is a federal crime to knowingly and willingly make materially
false, fictitious, or fraudulent statements, representations, or omissions on this certification.
131.
Ix.11 OlM. l.1 1l.A -
MY.1Wl4k
F11111,„',',i;;111111'11111 The Cover and Sump combination are
c _ -,'g ypig6 rated at the following
io. -� o.o o,G.o:G7 f
. _ : „Y; MAXIMUM ALLOWABLE FLOW RATES
III IIONll maw r'..:...•.s s� — 1 �," W 10326HF2 12" x 12" .-. ----
WC.IWM ._� - : GPM
— ': j 5'� pp0 3" Side Port Floor Mounted 416
•. ""'1'T'IN'y'i'i'rj1'1'1"'_' 4" Side Port Floor Mounted 484
,,_-. 3" Bottom Port Wall Mounted 308
- ,2l11IVCsc.010111cov,l - -
W01032aHF2 ,. - - 4" Bottom Port Wall Mounted 308
"(tall l lailil;l:iHil;l:I; iTti*_ 'x:'
1. 1- 1 .�
""701"111..10.l Y: Serial Number
• q.,l Ougllu•l -
A Warning—Suction Entrapment Hazard.
Suction in suction outlets and/or suction outlet covers which are installed in a small area and/or below the surrounding
surface can cause severe injury or death due to body entrapment hazard.
To reduce the risk of body entrapment,installation of the field fabricated sumps must be such that the top of the
mounted cover is a minimum of 11/2" above the finished pool surface over an area larger than 4o"on a diagonal.
nine RFI.F.ASFn Sinitic Date•71-Nov-21 I Icorr minintor
‘Opc, CATAWBA COUNTY
� 100A SOUI'IIWF,ST BLVD NEW'I'O BONE I828.465839A 28658 j RECEIPT
Thursday,May 11, 2023
1842 SM www.catawbacountync.gov V \V
L c0:7 Ci)/
PAYOR: CONOVER SWIM CLUB MAIN POOL
CONOVER SWIM CLUB MAIN POOL(OBOYLE,Carolyn)
PAYMENTS
TRANSACTION NUMBER: TRC-63812955-1 1-05-2023
PAYMENT DATE: 05/11/2023
PAYMENT TYPE: Check 2440
22218727
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-23-422480 110-580200-663000 Pool Inspection Fee-Seasonal $150.00
05-23-422480 110-$60200.663000 Pool Inspection Fee Seasonal S1$1)00
TOTAL PAYMENTS: $300.00
FLI-0000076
CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool
SITE ADDRESS: 221 5T11 AV NE CIR,CONOVER NC
Manager CONOVER SWIMMING CLUB INC,PO BOX 274,CONOVER NC 28613
B:8284550302 CONOVERSWIMMINGCLUB iiGMAIL-COM
OTHER-IMPORTED CONOVER SWIM CLUB MAIN POOL,PO BOX 274,CONOVER NC 28613
F:NONE
**NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator MICHAEL O'BOYLE,704 2ND AVE PL NE,CONOVER NC 28613
C:8283101606
receipt 05/11/2023 I1:53 Page I of I
CATAWBA COUNTY
��" G I00A SOUTHWEST BLVD, ` NEWTON,NORTH CAROLINA 28658 RECEIPT
Q ,,G PHONE:828-465.8399
Thursday,May 11, 2023
/g 4 2 sM www.catawbacountync.gov
PAYOR: CONOVER SWIM CLUB MAIN POOL
CONOVER SWIM CLUB MAIN POOL(OBOYLE,Carolyn)
PAYMENTS
TRANSACTION NUMBER: TRC-63815783-1 1-05-2023
PAYMENT DATE: 05/11/2023
PAYMENT TYPE: Check 2440
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
05-23-422485 110-580200-663000 Pool Inspection Fee- Seasonal $150.00
TOTAL PAYMENTS: $150.00
FLI-0000076
CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool
SITE ADDRESS: 221 STI I AV NE CIR,CONOVER NC
Manager CONOVER SWIMMING CLUB INC,PO BOX 274,CONOVER NC 28613
B:8284550302 CONOVERSWIMMINGCLUB@GMAIL.COM
GMAIL.COM
OTHER-IMPORTED CONOVER SWIM CLUB MAIN POOL,PO BOX 274,CONOVER NC 28613
F:NONE
**NO PEOPLESOFT ACCOUNT ASSIGNED**
Pool Operator MICI IAEL O'BOYLE,704 2ND AVE PL NE,CONOVER NC 28613
C:8283101606
receipt 05/11/2023 12:23 Page 1 of 1