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WELL'DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB-a 11-69 WELL DRILLING PERMIT
� Y 7875
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL Town (Lot N ber) DAT
SOUTH WINDSOR L�9 RLE RD. El2/1/?1
OWNER OF WELL
INDIVIDUAL IN BUILDER ❑ OTHER(Specify) e ARLO PRLSTIL�O
❑
OWNER'S ADDRESS
69 ASH ROAD, WAPPING, CONN.
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL PUBLIC, AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
-— - wln st from intersection and front of lot
_8
Location of lot19-aleast two roads Well location on lot and to house(if present)
Indicate North
4KT.
Approximate number of feet from well to nearest source of possible contamination: (r�
5
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.
in AP I Signa a APPLICANT'S ADDRESS REGISTRATION NO.
LAKE ST. a VERNQ a CONN. 100
1
APPROVED REJECTED
BY H fh Officer or Agent) DATE❑. ❑
,EMARKS
1 _
DIRECTOR OF HEALTH.