HomeMy WebLinkAboutApplication St. Marc Circle It a7,� Town of South Windsor — Health Department
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1540 Sullivan Ave., South Windsor, CT 06074— Mailing Address
1530 Sullivan Ave., South Windsor, CT 06074 — Office Address
Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: Cl t I 1'f``t �1�Q/n✓�cvY A/ ,(LC.(Gf/ "
ADDRESS:_ �� b'L CJ rc�(i �o� ��,/� ✓ �/
PHONE: EMAIL: /����✓�^„ fr F' i�nat «Y'C �l� /a--1
OWNER/ASSOCIATION
REPRESENTATIVE: ��i✓� y( u r✓e. LJ3
ADDRESS: � JNcrf� 6.3C r(r=yl� /¢J� f7t�•77 � (�`C� �O�
PHONE EMAIL: (0^-7
MANAGER(if different from owner):
ADDRESS:
PHONE NUMBER EMAIL:
POOL T /
OPERATOR: J �t� GS 4 /Q L✓r(?
ADDRESS �~I C�v VLYY06l&S 07 QX040
PHONE NUMBER� � 8 - �34CL�Q EMAIL
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool ✓Wading Pool Whirlpool/Spa
Dates Pool is Open: From to
Pool Capacity: JV 00D k`."Y-)S
Pool Make-up Water Source: Public Private
Disinfectant Used 0, \�OV44.,
The undersigned agrees to comply with Section 19-13-633b of the Connecticut Public Health Code:
Signature of Applicant Title Date
RECEIVED
'Please return completed registration form to the South Windsor Health Department Pool inspection requests must l hetluOlceks
prior to anticipated pool opening date.
SOUTH WINDSOR
HEALTH DEPT.