Princeton Crossing Pool Permit Application 4-22-2020 RECEIVE
3
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NIASSACH Sl:::ITS CITY OF SALEP �
f'f 13(3AR1)01"111:A['rt3 BOARD OF HEAL
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APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL ' I LLJ
NAME OF APPLICANaUl 6 TEL It
MAILING ADDRESS I t r � T L/
EMAIL ADDRESS N0 > 1 s
CERTIFIED POOL OP
ERATOR _
Name: 40 U0 I m m Cert#: TEL# g1l q -J/� _T'ffi
DATES OF OPERATION(if not annual): f l'�/�
DAYS &HOURS OF OPERATION:
TYPE OF POOL
Public
Semi-Public
Special Purpose
Surface Area sf Volume i 1 gallons Bather Load
FEE: $210.00 for year-round pools (�$140.00 for seasonal ) $40.00 Non-Profit
(ustbesu
.pay total with one chec4_payable to the„City of Salem)
This ansferable and must be reissued upon change of ownership.
In ach the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans
for su mitted to and approved by the Salem Board of Health.
Purshapter 63C,Section 49a,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,
h �eax returns and paid all state taxes required un er the law.
gna aI Dak SS#or Federal Identification Number
This section for office use only
Check# Date Amount