HomeMy WebLinkAboutWell New 600 Chapel Road (2) WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB-a 11-69 WELL DRILLING PERMIT 12122
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL(Town) (Street) (Lot Number) DATE
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OWNER OF WELL
®INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify) AIj=T C*MIM
OWNER'S ADDRESS
24 D.AnT Ba" H 4X, OM.
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ OTHERPUBLIC, AIR SUPPLY -❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Lo�ote well with spegto at least two roads,,showing distance from intersection and front of lot
Location of lot to at least t4 roads Well location on lot and to house(if present)
Indicate Northy
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Approximate number of feet from well to
nearest so rce of possible contamination:
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 provid4by the Board.This
permit is not valid until all information is filled in and it has been counter-signed by the Director of Health or his agent.
APPLI (Signature) / APPLICANT'S ADDRESS REGISTRATION NO.
C(JLAJM 8T• VXMNs COIN. 3.00
Town Health O er or Agent) DATE
IN APPROVED ❑ REJECTED ] 0970 S/— 7
REMARKS
DIRECTOR OF HEALTH
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PROPERTY OF
CHAPEL STREET SOUTH WINDSOR, CONN.
SCALE: 111 401 Date : M A
GRISWOLD. & FUSS, INC . o m m
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NO. 2683
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