HomeMy WebLinkAboutWell New 29 Brookfield Street (2) TOWN OF SOUIM WINDSOR
South Windsor, Conn.
No131 Date ........: ....:......... .......
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WELL DRILLER"S PERMIT
I, � .:..........:.......... ..........................................................................., of the firm of.. .......... .. . . .....
............................................................................_........................................................... (address) . . ... ....... ... ....... : .............
... ....... .. ......
.. ...............
hereby state that I (we) am (are) a well driller duly and currently registered with the State of Connecticut Water Resources
Commission and do make application herewith for a Well Driller's Permit in accordance with the provisions of Public Act 187
of the 1963 Session of the Connecticut Legislature, for a well to be drilled on the property of:
Nameof Property Owner:...... ...... r/ ................ ..........: ...... ............ ..............................................................:....................................................................
Addressof Property Owner:...... ?d......... ....... .... .... ...... ... ........ ...........................................................................
......................................
Addressof Premises on which well is located:..................... ..... ..................................................................................................................................................................
The approximate location of the well will be as shown on the reverse side of this permit.
The undersigned is aware that upon completion of this well the above data,together with a well log of info on required
under (c) and (d) of Public Act 187 of the 1963 Session must be sent to: r Resources Commission 23 tate Office
Building,Hartford, Connecticut on the form entitled"Well Completion ep which n _ ied to red drillers,
.. . ............................ ... . `................. . ...... . .....................
••Applicant
This permit is issued for a well located as shown to the above named well drill r in acco ce the Provisions of
Public Act 187 of the 1963 Session of the Connecticut Legislatu is........ ......'.
WHITE—ISSUING AGENT � . .... ...�i... ........... .4��- .. .. ...........
GREEN—APPLICANT Building Official
PINK—LOCAL HEALTH OFFICER
CANARY—WATER RESOURCES COMMISSION (Over)
Location of Well: Town of........ .... :: '� ....................
SKETCH SHOWING LOCATION OF PREMISES IN TOWN
(Show distance and direction from road intersection or other landmark)
�Il d sl 13 hGA,, t�
Diagram Showing Location of Well on Premises:
t
361
X
Route Directions for Reac W to from Nearest city or Village Center:
1 L