HomeMy WebLinkAboutWell New 23 Cliffwood Drive TOWN OF SOUTH WINDSQR
South Windsor, Conn.
101 WELL DRILLER"S PERMIT
... ......... .......................
... ...............S ............. .............. of the firm of
.................................................................................................................................... (address) ?
. ...... . . ...............
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hereby state that I (we) am (am) a well driller duly and currently registered**"
-.Wl 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 Cotic Legislat ,fora#a to be dri on property of:
Nameof Property Owner:..... ........ ..... .............................................................. ...... ... ..... .................................................................................
4b .............
Address of Property Owner:....... ...
Address of Premises on which well is located: ......
....................A.................................................................................
The approximate location of the well will be own 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 information required
under (c) and (d) of Public Act 187 of the 1963 Session must be sent to: Water Resources Commission, 223 State Office
Building,Hartford, Connecticut on the form entitled"Well COMPletiof R rt"which has bee I
'4� :R.WP rfi to registered-�d'llers.
........... .......... . ...... .................
This permit is issued for a well located as shown to the above named Applicant
,well driller in accordance with the Provisions ni
Public Act 187 of the 1963 Session of the Connecticut Legislature this.. day of.......... 7......................
.............196.16
WHITE—ISSUING AGENT
GREEN—APPLICANT ..........
PINK—LOCAL HEALTH OFFICER .......
CANARY—WATER RESOURCES COMMISSION (Over)
Location of Well: Town of. ........a "` * {..... r ....
SKETCH SHOWING LOCATION OF PREMISES IN TOWN
(Show distance and direction from road intersection or other landmark)
K
Diagram Showing Location of Well on Premises: ..
t:
r.:
Route Directions for Reaching Well Site from Nearest Uty or Village Center: