HomeMy WebLinkAbout2017-5-8 - 1 Amato Drive - Pool Application Form owof e_� Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
p y_ 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: U- f-S 4- µT 9CV i W (W i>5'4--1
ADDRESS 411WT-0 171�� S; lcJ (4) P-90, C-7 060'74-1
PHONE: 6 av .5 ���5 h ��� EMAIL s VeC-e WC-5tkor S at,, �' Cau9
OWNER/ASSOCIATION }r /�
REPRESENTATIVE: <S �q�jce h tsS, t✓0/�4 �Z l4aMQjP� '�C�df
ADDRESS: 3 1 lctw44� ' Aso ZUfl tl,QNt cK CT" 0 G0
PHONE: ��� S �a` k � EMAIL: -S � tQLJ UJQS�('d
MANAGER(if different from owner):
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ADDRESS
PHONE NUMBER EMAIL:
POOL
OPERATOR: L—
ADDRESS 1G37 JAq t-jk .Elyc/ , s, U9(1( L0'- CT Obc) 7 /
PHONE NUMBER I' 2bi 1 Vo EMAIL M )��� ��C s' I , C«---
FACILITY INFORMATION:
Check all that apply-
Indoor Pool � Outdoor Pool Wading Pool Whirlpool/Spa
Dates Pool is Open: From Ra. Z Qa ` Z c' (-/ to Zo
J
Pool Capacity.-
Pool Make-up Water Source: Public Private
Disinfectant Used: Q- 10 v(st
The undersigned agrees to comply with Section 19-13-11333b of the Connecticut Public Health Code:
�' (�, 7-17
Signature of Applicant Title f U Date
'Please return completed registration form to the South Windsor Health Department Pool inspection requests must be MydulY 2MJI.
prior to anticipated pool opening date.