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HomeMy WebLinkAboutWell New 49 Berle Road WELL'DRILLING MARV STATE OF CONNECTICUT PERMIT NUMBER WDB-4 "-69 WELL DRILLING PERMIT - 7875 STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 LOCATION OF WELL Town (Lot N ber) DAT SWTH WINDSOR / 9 MULE RD. �].2/lf�l OWNER OF WELL INDIVIDUAL 29 BUILDER ❑ OTHER(Specify) CART�O PR�'STILFi© ❑ OWNER'S ADDRESS 69 ASH ROADS WAPPING, CONN. PROPOSED BUSINESS TEST Est.No.of I DOMESTIC ❑ ESTABLISHMENT' ❑ FARM ❑ WELL People being USE OF served. WELL ❑ PUBLIC; AIR OTHER SUPPLY +� ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) 6 SKETCH OF WELL LOCATION wmg t js qm intersection and front of lot Location of lotj9-gL.Least two roads Well location on lot and to house(if present) Indicate North f"F`>gujELL f�BCC y Hof+ D` xT. Left �Ea;iq D Approximate number of feet from well to 75 nearest source of possible contamination: The undersigned is aware that upon completion of the well,a"Well Completion Report':' containing construction details and information required under Section 6 of Public Act 659 must be sent to the owner,the Board and.the Water Resources Commission on the form provided by the Board.This permit is not valid until all informs- tion is filled in and it has been counter-signed by the Director of Health or his agent. AP I Signot APPLICANT'S ADDRESS REGISTRATION NO. LAKE ST. 9 VMNQ5 a CONN. �«< 100 oe BY H th Officer or Agent) DATE 1❑APPROVED REJECTED 'REMARKS .4 i 1 DIRECTOR OF HEALTH.