Rouss City Hall Telephone: (540) 667-1815
15 North Cameron Street FAX: (540) 662-5803
Winchester, VA 22601 Website: www.winchesterva.gov
APPLICATION TO FILL SWIMMING POOL
The undersigned applicant hereby requests that their swimming pool, located at
, be filled utilizing a City of Winchester fire hydrant
in accordance with the terms of City policy adopted January 13, 1987. The pool to be filled will
hold approximately gallons of water. The applicant agrees to pay the
$100.00 non-refundable fee and for actual water used at the prevailing City rate. In
consideration of the City’s agreement to fill said pool, the undersigned hereby releases, holds
harmless and agrees to indemnify the City of Winchester, its agents, and employees, from any
responsibility, judgment, damages, or other charge for any claim, demand, suit or other action for
any and all property damage or personal injury resulting from or related to the pool filling
operation.
Signature:
Name:
Address:
Telephone:
Date Request for Pool Filling:
For office use only:
Meter reading start Deposit rec’d date
Meter reading finish Deposit rec’d by
Gallons used Date of filling
Water rate Utilities staff
Total billed Fire Company
“To provide a safe, vibrant, sustainable community while striving to constantly improve
the quality of life for our citizens and economic partners.”
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