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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF MANSFIELD
BOARD OF HEALTH
APPLICATION FOR A PERMIT TO OPERATE A SWIMMING POOL
Application is hereby made for a permit to operate a public, semi-public, or
wading pool. This pool is to be operated according to the minimum standards
for swimming pools set forth in Article VI of the Sanitary Code of the
Commonwealth of Massachusetts.
OWNER: if �a l F -a /& TEL. _N0: � 1 ` � r/
ADDRESS -/1`& S'C�ze.�/
TONIN: STATE: 'A/ ZIP: e z- e) ,V p
LOCATION -OF -POOL:
ADDRESS: S" '_-
TYPE -OF -POOL: Ttz yet4W LENGTH: r .l WIDTH: -2 f � VOLUME:
MINIMUM/MAYMUM DEPTHS:
.3 2 d to
SKETCH (A detailed plan must be filed with original application.)
SIZE: SWIMMING_AREA:�d'e-v, 'TION-SWIM_AREA:, oGO,s IVING_AREA: r
SOURCE-OF-WATER:
DISPOSAL_ OF_SEWAGE _AND WASTEWATER:
TYPE -OF _ FINISH: 1�'h SCUM -GUTTER:
DECK_ TYPE_AND_WIDTH: ` �°c�r�ev�f� SKIMMERS WEIR_LENGTH:
TREATMENT SYSTEM (Kind of ,filters, etc.):
DISINFECTION_METHOD (Method, type, capacity, etc.):
CHEMICAL TREATMENT (Feeders, capacity, quantity, etc.):
REMARKS:
Signature
Title�J�i�-��� ��-
Date%11_,2,} 61
NOTE PLEASE Permit expires on December 31st yearly.
Fne is $75.00 per year, payable by check to
Town of Mansfield, 50 West St., Mansfield 02048