HomeMy WebLinkAboutWell New 20 Berle Road WkLL DRILI•JNG BOARD STATE OF CONNECTICUT PERMIT NUMBER
wD6-4 >i-69 WELL DRILLING PERMIT 2086
1yJ STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION rocV
ELL(To (Street) f (Lot Number) DATE /
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OWNER OF WELL T
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify) a ly 0
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_ OWNER'S z
RES
ti PROPOSED , BU INESS TEST Est. No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
�. USE OF served.
PUBLIC AIR
WELL ❑ THR
SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ SpeEfy} fC
SKETCH OF WELL LOCATION
Locate well with respect#o at # wo roads,showing distance from intersect4on and fi"ont of lot
t Locatjon of.lot to at least two roads t= Iotionsw,aaNkgecto hotsse(if pYese»te `-
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Indicate'hfiiih
n
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Approximate number of feet from well to
nearest source of possible contamination: O
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 informa
Lion is filled in and it has been counter-signed by the Director of Health or his agent.
APP Si lure) APPLI ANT'S D RESS REGISTRATION NO.
(/PG/?off an`i. /r1J4
Y(T wn Healt Officer or Agen) DATE
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❑APPROVED ❑ REJECTED
W _REMARKS -
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DIRECTOR OF HEALTH