HomeMy WebLinkAboutApplication Twin Circle Drive May, 8. 2017 12 :40PM No. 5243 P. I
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go Brainard Road, Suite :105
Hartford, CT o6114
PHONE: (86o) 548-9773 FAX; (86o) 548-9708
DATE: 6 ll:�61 ITT--
FAXTO: I-pw)a () ,C SO(A�V\W\VCISO
FROM: �Y-ka
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IVAGES: 2-
(iaduding cover page)
May. 8, 2017 12:40PM No. 5243 P. 2
^ k o, Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
^� �'., 1530 Sullivan Ave., South Windsor, CT 06074-Office Address
A y Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: bij JfQWQ0C\ �UYI(�1\�nir11U.YY� f��SOC�Ca1�Gn I�Y�C
ADDRESS \O 1 - l01 - 'Tl.U1'(\ 0 r(1e p6ye SUU-Y)rN W1'fd S0 y' CT Ll4 01-1
PHONE: EMAIL. 't"IYIC& vmna. Qr,.eme-nt _cZrn
OWNEWASSOCIATION
REPRESENTATIVE: Y_en Le W�' P63&j i C k"(:Y\ y c QS lC e n--,
ADDRESS:A oe6 'C-w I'1 O foc bY1 Ye SUU�o1 W�Y\�Cr
PHONE:S&uQ, 'UL- L1 - 405 q EMAIL: �-?�-\N �(� C 01M
MANAGER(if different from owner):
-i VA C-U r�r �'rc, r�-c-� NkCknCaer C�E W k('k (Xle,rnr�n-r .\r,
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ADDRESS: rl G `C )!aAY\ r6 Ef�a C
PHONE NUMBER <lUO-SLIJ-CITT" , EMAIL: "Ock r� rtt cr-TIn
Celt t�` zoo Q�TLI
POOL 1 ��
OPERATOR: (SCtXha ADDRESS -P, D 15�y 701 611 C17 04 a,2,
PHONE NUMBER k&D-5� 01/ EMAIL M-94Co FSe�
FACILITY INFORMATION:
Check all that apply: v
Indoor Pool Outdoor Pool X Wading Pool Whirlpool/Spa-_
Dates Pool is Open: From _ " �n6b 1 -7 to���Sr7
Pool Capacity:
Pool Make-up Water Source: Public Private
Disinfectant Used:
The undersigned agrees to comply with Section 19-13-133316 of the Connecticut Public Health Code:
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Signaltw.b of Applicant Title V Date
RECEIVED RECEIVED
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"Please return completed registration form to the South Windsor Health Department. Poo rts?peclhon requests must be scheduled 2 weeks
prlor to anticipated pool opening date ' INDSOR
SOUTH _,� ,�„�'