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Home My WebLink AboutColonial House Apts App 500072 05 12 23 ENVIRONMENTAL HEALTH ri) 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 MAKING.LIVING.OUTER. Email: EHAdmin@CatawbaCountyNC.gov Application for Public Swimming Pool Permit Pool Information R) +�b( iSel Name of public swimming pool: ( !C) 01'1 in )4O UI('. Ara I 0 -‘2t' D E D OO Street address: 1 Y( t t I Q-cL N 1- pp City: )4 J (_KGV c State: 1��C. ZIP: c A,L}f Type of public swimming piol Swimming pool nWading pool nSpa nOther (describe) Date constructed or remodeled: afore May I, 1993 (After May 1, 1993 RECEIVED Dates of operation: Opening date: Closing date: Opening � h4 t Hours of operation: time: �LF-rn Closing tie: 1 2 2023 Owner Information Environmental Health icrli(3L hbtlSt,, Name of owner v)rv11 La. 0 G6. Tl\Vr.sicr L1.2 Owner email:guair;i-tv-e_r21u..14- ca ki .Cc 1 Yl Mailing address: 11) n . ' ) v& 4)IUck. I JJ City: +-tl C,KJJ"" State:NC ZIP: 4:C( Contact Person: a vvx Phone#: LL ,321: VIL Operator(On-Site Manager)Information Pool operator. Ken \/\;(-1-tic . Phone#: ��15 '" � cvsS I Street address: I I Yeei CtLQ,, �i L City: I Li State:NC ZIP: .-))�(00 / Pool operator trained by: National Swimming Pool Foundation (Certificate#: ,her(please specify) I t -L( "I C t C.LCt I, f e c R FL uric da. r o-v Application Submitted by: fir^ /4t 14 ' [iOwner nOperator A le06 Signature of Applicant: / .td 4..•. Gc c Date: :75 , C,; 3 o Purpose General Sta lute 130A482requires the Commission Health Services toadoptrules governing public swimming pools.The rules in ISA NCAC I SA.2300 require the owner or operator to apply annually for an operation permit for oath public swimming pool.This foam is to slew owners or operators of public swimming pooh to apply for pemdts.Preparation:The information requested on ids form is to be completed by the pool owner or a designated representative ofthe owner.The completed epplatien is submitted to the loci health department for the county n width the public swimming pool is located.A separate application must be completed for each pablr swimming pool Copies:Original to be maintained at the local health department Disposition:Please refer to Records Retention and Disposition Schedule for County/DisMA Health Departments which are published by North Carolina Division of Historical Resources. Reorder.Additional Forms may be ordered Fran:Division of Environmental Health, Deportment of Environment and Nand Resources,1630 Mail Smite Cada,Raleigh,NC 27699.1632,(Courier S2.01.00) D EN R 3961(Revised4/03) Environmental Heahh 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 0,01 On I C A )40(. e., illPt{j ID# 1. Pump Flow r Pump Manufacturer �n 41 OS Model#,S ,ILf.1-iu 8s-r Horsepower ),5 Maximum Pump Flow at highest speed FROM PUMP CURVE: I I 0 _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? YES 0 Flow meter manufacturer Flow meter reading 1 1 0 GPM 2. Drain Sump Measurements Is drain cover sumpless? YES/NO Sump manufacturer and model no* (1'.JO Q(r)le, OR: Field built sump(circle if yes) Diameter of pipe entering sump 1 a inches. Pipe enters throug BOTTOM/ IDE of sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump inches. Sump dimensions I 0 tra S 3. Drain Cover Data—MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-Attach Instructions to form. Number of main drains on each pum c Distance between main drains(on centers) feet inches n Cover/grate manufacturer DX - } ,model ST - Refry() ___,VGBA approval 2008/2017(circle one) Flow rating from instructions:✓/ 0 0 gpm Cover(s)located on pool 'loor wall(circleone) Date installed 4%/jq ___Lifespan _ EXPIRATION DATE ,5 L;�i 4. Equalizer Covers ///"` Number of operable skimmer equalizers Have the equalizers been permanently disabled? YES/NO n /�J� Equalizer fitting Manufacturer ,Model ,Lifespan I `0 t 2�� Y1L.rS 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 .- 1/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 ROi" (G. GS Phone number: )s-n'32141(1 U Signature ' Gv• Date 5:0 3 NCDHHS Revised 4/1/2022 for immediate use. 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 . ,_(`• t Atnerican.'rinnning,Pool and Spa-Lssoc•iaiion k`u►t .snr r. • Licensed Aquatic Facility . Technician Foundations Certification hy' A/) •..,e.. .,i,,v1-, *IA 'y as an Operator of Aquatic Facilities by the American Swimming Pool and Spa Association r IAPf Regis?ration No.0.5J I •0 I is hereby licensed and registered - ;Zl—— r ' ATE LI TSED • ATAp—� IRES d 1, . IhSTR 'TOR r HAIRh1AN .ate' .x % r. _ .{Y' �4'A CATAWBA COUNTY ��' G 100A SOUTHWEST BLVD d NEWTON,NORTH CAROLINA 28658 RECEIPT 115 0 PHONE:828.465.8399 Friday,May 12, 2023 18 4 2 snt www.catawbacountync.gov PAYOR: Colonial House Investors LLC Colonial House Investors LLC PAYMENTS TRANSACTION NUMBER: TRC-63897788-12-05-2023 PAYMENT DATE: 05/12/2023 PAYMENT TYPE: Check 3297 check received in Hickory 5/9/23 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 05-23-422608 110-580200-663000 Pool Inspection Fee-Seasonal S150.00 TOTAL PAYMENTS: $150.00 FLI-0000 159 CASE TYPE: Food&Lodging Institutions WORK CLASS: 50-Seasonal Swimming Pool SITE ADDRESS: 818 2ND ST NE,HICKORY NC Manager COLONIAL HOUSE INVESTORS LLC,818 2ND ST PL NE,IIICKORY NC 28601 B:8283269170F:NONE COLONIALHOUSE a CAPSTONEMULTIFAMILY.COM Paid By COLONIAL HOUSE INVESTORS LLC,245 W MAIN AV,GASTONIA NC 28052 **NO PEOPLESOFT ACCOUNT ASSIGNED** Pool Operator RICKY KIZER,818 20TH AVE PL SE,HICKORY NC 28602 B:9806369762 receipt 05/12/2023 13:59 Page 1 of I