HomeMy WebLinkAboutWell New 0000 Berle Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB-4 11-6' WELL DRILLING PERMIT 4 G 9 5 4
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
South Windsor Berle Roach 25
LOCATION OF WELL (Town) (,Street) (Lot Number) DATE
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ME 1977
OWNER OF WELL 1
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS �,1
26 Hamilton Court, Enfield, Conn,
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ PUBLIC ❑ INDUSTRIAL ❑ AIR ❑ (Specify)OTHE 1 Family
SUPPLY CONDITIONING
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
Location of lot to at least two road Well location on lot and to house(if present)
34
A CTUA L..
Indicate North �
Approximate number of feet from well to
nearest source of possible contamination: 75 feet
The undersigned is aware that upon completion of the well, a"Well Completion Report' containing construction details and information required under Section
25-131 of the 1969 Supplement to the General Statutes must be sent to the owner,the Board and the Water Resources Commission on the form provided by the
B rd. This permit is not valid until all information "led in and it has been counter-signed by the Director of Health or his agent.
P ICAN ignature) APPLICANT'S ADDRESS I REGISTRATION NO.
Dufford` Drilling Company
Fieb on
Town Health Officer or Agent) DATE
APPROVED ❑ � �`�I �,_ 0 �C�^Z
REMARKS_._-----_—
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD