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Home My WebLink AboutFLI-08-2023-202845.tif allidLNIISIN ENVIRONMENTAL HEALTH VW 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 01e1ee.LIVING.ochre. i:iiu:il: ClUitxilliliisirntivr'AssistaillSOAntuwltaCourityiaCgov Application for Public Swimming Pool Permiti'7 f'Pool Information Vti-t8_)D)3 �✓'')JJ Lr Name of public swimming pool: Amavi Sherrills Ford `) 0) C3U0 Street address: 4050 Freesia Street City: Sherrills Ford State: NC ZIP: 28673 Type of public swimming pool_/Swimming pool nWading pool Spa Other (describe) / Date constructed or remodeled:nBefore May I, 1993 Elfter May 1, 1993 \1 e4(I/C&/sc pdo I Dotes of operation: Opening dote:OB/21/2023 Closing date: 12/31/2023 OPedng Hours of operation: time: 8am Closing time: 8Pm t.; J,c.::, _117_,fit.-.)itvi.. Name of owner: MCREF SFR 1 Sherrills Ford LLC Owner email: amavisherrillsford@ eft ill Came‘ places. cowl Moiling address: 4050 Freesia Street City: Sherrills Ford State:NC ZIP: 28673 Contact Person: Lyndzi Vaughn Phone#: 828.688.7180 Operator(On-Site Manager)Information Pool operator: Lyndzi Vaughn Phone#: 828.688.7180 Street address: 4050 Freesia Street City: Sherrills Ford State:NC ZIP: 28673 Pool operator trained by: QNationol Swimming Pool Foundation(Certificate#: JFLL5N5 ) ❑Other(please specify) Pool and Hottub Alliance Application Submitted by David Storey nOwner ❑Operator Signature of Applicant: )\ Th Date: a)R, 1 f t 3 Purpose General Stntut,I30A.282 requtr,o ho commission Health Slrviusto adopt ruin governing publtswietming pools.Tim minim in 15A NCAC I SA-2500 require the ewoer or operatic to apply'nasally for at operation permit for ens pubht swimming pool,This form is to An ownen or aperotas of pubic swimming pods to ripply for peewits.Proporation:The intasalion requested on this forte is to be completed by the pool owner or a designated eapreserhotive of the owaes.The completed applies art is stkrOion to the lord health deportment for the teuoty in whirls the public swimming pool is located.A swot*appRttttion earn be completed for each palter swimming pool Copies:Original to be moiatoincd at the local health deportment,Disposalaa Please refer to Recalls Retention and Disposition Schedule for County/District Hoobh Deportments which ors pubtched by North Carolina Division of Histaial Resoaas. Reorder:Addition!Forms may be ordered iron Division of Eavironmentol Heath, D epartmenl of Environment and Nahwd Resources,1630 Mal Sono Ccn*er,Raleigh,NC 27699.1632,(Courier 52-01-00) DENR 3961(Revised 4/03) Envirenmentol Hedih Service,Section(Review 4/06) catawba county public health 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 A e j, She_ t`ck ID# 1. Pump Flow Pump Manufacturer Model# F-E—2-0 (1O 2.ZC(l)I-Iorsepower S Maximum Pump Flow at highest speed FROM PUMP CURVE: "2_SSO gpm. Pump us Circulation jet/feature(circle one) Has pump been serviced(disconnected from power for any reason)or changed out in last 12 months? YES NO Flow meter manufacturer l3 v t L�ISn. 1-<.. Flow meter reading Z03 GPM 2. Drain Sump Measurements Is drain cover sumpless? YE'1 P Sump manufacturer and model //L c.v,a Sc,is, 4-1,L.Ja Sir — l2 (Z OR: Field built sump(circle if yes) Diameter of pipe entering sump b inches. Pipe enters through BOTTOM SIDE f sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump ] inches.Sump dimensions 1 2-I(Xi 2,It 3. Drain Cover Data-MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-Attach Instructions to form. Number of main drains on each pump 2. Distance between main drains(on centers) 5 feet (7 inches Cover,/grate manufacturer L caw(.0 r- ,model tr•l L ) SG-t2.(2.VGBA approva t t) 2017(circle one) Flow rating from instructions: 3 6 S ___,gpm Cover(s)located on poo loor all(circle one) Date installed Qi(Sa(2-3 Lifespan t K ee,rS EXPIRATION DATE 9)1 (1'33 4. Equalizer Covers ; Number of operable skimmer equalizers 0 Have the equalizers been permanently disabled? CD NO 4—�1 ^s' Equalizer fitting Manufacturer r'3 Model 1 Lifespan 1� Bulkhead adaptor Manufacturer N I.A .Model N(A ,Date Installed IJ ) to Diameter of equalizer pipe v.) ),pt• Cover is located on(circle where mounted):Floor/wall Equalizer fitting maximum flow rating _gpm. Date equalizer cover/grates installed N J pti EXPIRATION DATE: 1'1( A 5. Safety Vacuum Release System(SVRS)-Safety Vacuum Release System manufacturer/model#- tti.)(A You will be required to demonstrate effectiveness during permitting inspection.Date last tested t^)/A 6. Vacuum Line Choose One No vacuum line in pool OR Protective cover on vacuum lines installed before May 1,2010,OR )X 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 0.-1Nr; -L(iSPhone number: c 0 3— 51,—2-0 65- ,,t,,,rrrrrrrl•r Signature Date �� 30( ZUZ `�,,-CN CAR() C EE3� NCDHHS OCf '/� . Revised 4/1/2022 for immediate use. _L. -n • 'Z9. 0/1O/2O2 "': •• '"HER M r•rrrru �5 ',N catawba county public health Pool Drain Safety Compliance Data PERMIT CANNOT BE ISSUED IF FORM IS INCOMPLETE A separate form is required for each pump including� l circulation,jet or feature. Name of Pool 1't ^'",'V; S \, ter-r-; (1S R�cC� 1D# 1. Pump Flow �" Pump Manufacturer +jam t/L< <i:r" Model# Stoke�-Flp V'ST Horsepower S (3L-1'Zoo Maximum Pump Flow at highest speed FROM PUMP CURVE: 1%O gpm. Pump use:Circulation/jetiagpircle one) Has pump been serviced(disconnected fmm power for any reason)or changed out in last 12 months? YE NO Flow meter manufacturer ►�f A Flow meter reading uj IA GPM 2. Drain Sump Measurements Is drain cover sumpless? YE`( Sump manufacturer and model �� e.fll lL)CT' l Q(4.l-\E Z.iA kL OR: Field built sump(circle if yes) Diameter of pipe entering sump 3 inches. Pipe enters through BOTTO<SlDE)uf sump(Must circle one) Distance between highest point of outlet pipe and top edge of sump ,01. inches.Sump dimensions l l )q 11 3. Drain Cover Data-MUST BE INSTALLED PER MANUFACTURER'S INSTRUCTIONS-Attach Instructions to form. Number of main drains on each pump Z Distance between main drains(on centers) 1---1 feet S inches Cover/grate manufacturer 1kc‘v\t,,,)&r& ,model 1,J(7(Q kE, F VGBA approval 2008/r l ircle one) Flow rating from instructions: "2.-6 gpm Cover(s)located on poo Floor/ all(circle one) Date installed ()`1?)(7- Lifespan 5 ,y r-S EXPIRATION DATE ( \ 20 Z B 4. Equalizer Covers Number of operable skimmer equalizers 0 Have the equalizers been permanently disabled?ail/NO 5 M Equalizer fitting Manufacturer "`) d's ,Model I')(A ,Lifespan tJ I Bulkhead adaptor Manufacturer v->1 fi .Model N( A ,Date Installed "f N Diameter of equalizer pipe csi lJ! Cover is located on(circle where mounted):Floor/wall Equalizer fitting maximum flow rating Date equalizer cover/grates installed A EXPIRATION DATE: A 5. Safety Vacuum Release System(SVRS)-Safety Vacuum Release System manufacturer/model#- t A You will be required to demonstrate effectiveness during permitting inspection.Date last tested tti(p 6. Vacuum Line Choose One No vacuum line in pool OR Protective cover on vacuum lines installed before May 1,2010,OR x 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 CAA r":a}9 i eJ- V-\_ Ct.i W.Phone number: gO 3— S Signature (4 *ft. 6& — Date al30( ? nZ3 r(N CA Roe, ,,,, • NCDHHS Revised 4/1/2022 for immediate use. S� • Nrc'::: G`Z`�; op M. #Pd CATAWBA COUNTY 100A SOUTHWEST BLVD 1) NEWTON,NORTH CAROLINA 28658 RECEIPT PHONE:828.465.8399 Thursday,August 17,2023 1$4 Z sM www.catawbacountync.gov PAYOR: Storey,David PAYMENTS TRANSACTION NUMBER: TRC-71068923-17-08-2023 PAYMENT DATE: 08/17/2023 PAYMENT TYPE: Credit Card 309577340 INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT 08-23-427036 110-580200-663000 Pool Inspection Fee-Year Round $200.00 TOTAL PAYMENTS: $200.00 FLI-08-2023-202845 CASE TYPE: Food&Lodging Institutions WORK CLASS: 53-Year-Round Swimming Pool SITE ADDRESS: 4050 FREESIA ST,SHERRILLS FORD NC 28673 Owner MCREF SFR 1 SHERRILLS FORD LLC,1001 MOREHEAD SQUARE DR SUITE 350,CHARLOTTE NC 2 B:7049097213 JHOLBROOK@MCRTRUST.COM Paid By DAVID STOREY,2820 DONEGAL DR,KANNAPOLIS NC 28081 C:7043522877 **NO PEOPLESOFT ACCOUNT ASSIGNED** receipt 08/17/2023 16:08 Page 1 of 1