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WELL DRILLING BOARD STATE OF CQUINSeTICuT PERMIT NUMBER
F WDB-a 11-69 WELL DRILLING PERMIT 2085
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF.VELL(Town) (Street) (Lot Number) DATE
OWNER OF WELL
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❑ INDIVIDUAL BUILDER ❑ OTHER(Specify) j, `U- /��J^ � le U
OWNER'S A D RESS
Z- - ;�j 0�� I C
0.- ? /f x4 of 1, __4tl
11, BUSINES TEST Est.No.of
PROPOSED IK DIIESTIC ❑ ESTABLISHMENT El FARM ❑ WELL People being
USE OF ;' served.
PUO
C AIR OTHER
WELL ❑ SUPPLY
UPP Y ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect.,to� `-two roads,showing-distance from injersection and front of lot
Location of lot to at least two roads «' - .Well location on fotand'tii house, pYeseiit)' ..a aiir
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Indicate Nbrth
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Approximate number of feet from well to !
nearest source of possible contamination: J ��
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-
tion is filled in and it has been counter-signed by the Director of Health or his agent.
APP ( ature APP CANT��°DRESS REGISTRATION NO.
C7 C41 A4. /U o
BY io Healthfficer or Agent) DATE
❑APPROVED ❑ REJECTED
REMARKS — - --- -
DIRECTOR OF HEALTH