HomeMy WebLinkAboutApplication Twin Circle Drive May, 8. 2017 12 :40PM No. 5243 P. I
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PHONE: (86o) 548-9773 FAX; (86o) 548-9708
DATE:
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(iaduding cover page)
May. 8, 2017 12:40PM No. 5243 P. 2
Town of South Windsor — Health Department
1540 Sullivan Ave., South Windsor, CT 06074- Mailing Address
r-, 1530 Sullivan Ave., South Windsor, CT 06074-office Address
A Phone Number: (660) 337-6173, Fax Number: (860) 644-1930
F��Gs°`'`��` PUBLIC SWIMMING POOL REGISTRATION FORM
FACILITY NAME: n_ L
ADDRESS: tut - 1100- '_ U1XA p6ye <lUuthvgnrdSor CT LlQU1`i
PHONE: CP0�-5L(R'- 911'� EMAIL. 't'hC& eme-n-V -Cf3Yrl
OWNEWASSOCIATION
REPRESENTATIVE: P n L W�S NSSUC i C.U"( P r;CS k(Se X 3
ADDRESS: �U�S 'I1 111 LirG1e 'Dr�Ye �(,I oio q
PHONE: 'C oC 'UL LA -EMAIL: �-? %,-'�N-1 Pi ko\ . C om
MANAGER(if different from owner):
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ADDRESS:
PHONE NUMBER <IU0-SLjJ-CI_I"1'4, EMAIL: kAoanr- y-ft Cr,-M
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POOL
OPERATOR: �U.Y�a.
ADDRESS �� D !J6 70/ t c7- 64 OC", -
PHONE NUMBER I5���0/�5✓ EMAIL /j?a/C�FS�� ��1d11-00k'P7
FACILITY INFORMATION:
Check all that apply: v
Indoor Pool Outdoor Pool
X Wading Pool a Whirlpool/Spa
Dates Pool is Open: From 0 �0n6 '� -7 to l �� S��(
Pool Capacity:
Pool Make-up Water Source: Public Private _
Disinfectant Used:
The undersigned agrees to comply with Section 19-13-1333b of the Connecticut Public Health Code:
d1e)a 5
Signa of Applicant Title Date
RECEIVED RECEIVED
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-Please return completed registration form to the South Windsor Health Department_ Pool Inspection requests must be scheduled 2 weeks
prlorto anticipated pool opening date
SOUTH r?iNDSOR