HomeMy WebLinkAbout949 Pleasant Valley Road (2) Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
p ^ 1530 Sullivan Ave., South Windsor, CT 06074-Office Address
c Phone Number: (860) 337-6173, Fax Number: (860) 644-1930
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PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: tlA V.�\V v') 1M ScpC• 1n,c
ADDRESS: ` ���5?r`c V ILtl S . 13%vId SO Y
PHONE: PCs O 36 ' Co 640 EMAIL:.. A-\ �e-�Q-J�N` C • CSbT%k
OWNER/ASSOCIATION \
REPRESENTATIVE:: JO e
ADDRESS: `A asir�V�Mtp� �U► e- 33d �IO�O�av�b�r►�
PHONE: ��� �{3d ' �oC��O EMAIL: \C�� �� '��3 \\C. . �VV\
MANAGER(if different from owner):
ADDRESS: f�5 C--4\ - Cs�
PHONE NUMBER: EMAIL:
POOL
OPERATOR: �'rzs"
ADDRESS (,.0 3 tv
PHONE NUMBER 55U0 -1 77 '6 • %I 60 EMAIL
FACILITY INFORMATION:
Check all that apply:
Indoor Pool Outdoor Pool Wading Pool Whirlpool/Spa
Dates Pool is Open: From —1 .4, ./ to
Pool Capacity: RECEIVED
Pool Make-up Water Source: Public Private ✓ MAY 2 4 7018
Disinfectant Used: SOUTH WINDSOR
HEALTH DEPT.
The undersigned agrees to comply with Section 19-13-1333b of the Connecticut Public Health Code:
ii 6'!1/�flt.iy.�•/ ��s:i.��V:lJ'1 ��/��+�1.� J C� lU
Signature Applicant Title Date
"Please return completed registration form to the South Windsor Health Department. Pool inspection requests must be scheduled 2 weeks
prior to anticipated pool opening date.
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- V Iftl. 3H
OaP —N I *<utine Inspection 0 Indoor Pool
Town of South Windsor—Health Department 0 Re inspection 9�utdoor Pool
1540 Sullivan Avenue,S.Windsor,CT 06074 0 Complaint 0 Wading Pool
Phone: 860-337-6182 Fax: 860-644-1930 0 Other: 0 Whirlpool/Spa
Public SwimmingPool Inspection Report
Name of Facility: U d�X1(� (� Inspection Date:Ob
Address l� b.� a fLAI Phone:
Items marked with an X indicate non-compliance with Cr Public Health Code(Section 19-13-633b). Violations must be corrected by the listed compliance date.
a-4 Life Saving Equipment b-12' Vacuuming
Ring buoy <15" inner diameter, attached to
50ft length of%" line Pool vacuumed to maintain cleanliness
Life pole/shepard's crook with blunted ends, a b-13 Accessibility to Pool Area
minimum of 12ft in length Outdoor pools surrounded by barrier(>4ft)
b-1 Pool Construction / Outdoor pool entry gates self-closing and self-
latching
Pool in good repair V
b-2 Supervisory Personnel Pool access restricted when pool is closed
Knowledgeable pool supervisor onsite - b-14 Lifeguards
List of personnel provided to Health Dept. Warning signs if no lifeguard on duty(letters
>4" high)
b-4 Pool Water Clarity
Warning signs visible from all entry points in
6" secchi disk at pool bottom visible
b-5 Pool Water Disinfection pool area
b-15 First Aid Kit
Automatic Feeder Used
>0.8 mg/liter Free Chlorine Kit filled, ready for use, materials current
Amer. Red Cross 24-unit first aid kit or equiv.
b-5, b-6 Test Kits
DPD Test Kit onsite (for disinfectant and pH) b-16 Emergency Telephone
Telephone readily available in pool area
b-6 Pool Water pH
Value between 7.2 and 7.8 b-17 Signs
b-7 Records and Testing "All persons shall bathe with water and soap
before entering pool
Residual disinfectant & pH tested prior to daily "Anyone having a communicable disease shall
opening not use the pool"
Daily pool testing records kept "Spitting, or blowing the nose in the pool is
b-8 Decks, Dressing,Toilet&Shower Rooms prohibited"
Clean, good repair, well ventilated "Running, boisterous or rough play is
0.5%chlorine cleaning solution for floors prohibited"
Shower water 90—105 degrees F b-18 Emergency Communications
Adequate toilet facilities Directions to nearest telephone and first-aid kit
b-9 Equipment rooms/areas&Equipment ✓ posted at entrance
Maintained in good repair, clean/sanitary
Telephone numbers (print>.25 ) of police,fire,
J Skimmers,gutters, strainer baskets clean and in hospital and EMS
!� good repair b-19 Registration
Drain grates compliant Name of owner or owner's agent, address and
b-10 Deck Equipment location on file
Handrails provided on steps, step holes, and c-1 Depth Markers
!/ ladders / Markers on rim at min and max deptp and
Equipment properly secured ✓ points of slope change
b-11 Pool Chemical Storage Markers visible from pool deck and from within
✓ Stored in a cool, dry, clean, well-ventilated area ✓ pool
Containers stored tightly closed
Public Swimming Pool Inspection Report
2
c-2 Lifeguard stands Comments:
Lifeguard stand raised at least 4ft
Filter Type:
Lifeguard stand located pool side adjacent to
deep end Filter Size:
c-4 1 Sign
"No diving is permitted off the deck into Flow Gauge (gpm):
hallow areas of the pool"
TO rate (vol./flowrate x 60):
Additional Requirements for Public Spas:
e-1 Pool Water Disinfection Filtration rate (gpm/sf):
Free available chlorine residual >1.0 liter
when Z
when spa in use Free Chlorine Total:
e-2 Pool Water Temperature c,
ater temperature shall n exceed 104 pH. i b
de rees F
e-3 Dep Markers h�
Minim 2 marke located on rim or
adjacent poo S I
e-4 Precaution ins r C� ,, _Wv
"Elde/Diase,
%Dbetes,
d those suffering from
Heart High or Low BloodPressenter the spa"
"u upervised use y children is prohibited"
Zo not use while un er the influence of
ohol/drugs" �1nUU►l.e` [ �d
"Do not use alone" l �
"Observe a reasonable ti limit (preferably Vlyl� SIM Ui �(
less than 15 min.): long exp sures may result
in nausea, dizziness, or faintir "
e-5 Oils, Body Lotions,and Soaps j
Oils, body lotions&soaps mustle removed
prior to spa use
Pool Supervisor: �%� � Date: S
(Print Name)
( ' nature)
Health Inspector: Title: Incl. 41�aA
C'l T;, s�
(Sign lure)
DATE OF COMPLIANCE: Sr l Z I Re-inspection Required: A YES �NO
S Windsor—April 2011