HomeMy WebLinkAboutWell New 36 Cliffwood Drive TOWN OF SOUTH WINDSOR
( South Windsor, Conn.
WELL DRILLER'S PERMIT
........................ . .. . ......... .. .. ........................, of the firm of........... �,l;V...... ........... ............................................
.......I, �.. ..a..._..... (address) ....................................................._.............................................._................ ...........
... ..... . . . .. .......
he reb to that I (we) am (are) a well duller duly and currently registered with the State of Connecticut Water Resources
Commission and do make application herewith for a Well Driller's Pernjj,1t in accordance with the provisions of Public Act 187
of the 1963 Session of the Conn icu Legi la , for a ell to be d4jad,01 the property of:
J.
Name of Property Owner:.....:. ...... .. .. ..... ._..... ^.........
Address of Property Owner:....................�....�.r..s.r.••• ... ...: ....,:"�`.�......... ...................... .. .t..... ................................................................::.....................
.. R
................................................. ... ..Address of Premises on which well is located:... .......
The approximate location of the well will be as 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 Completio �whichn su p edtoregtstered t711ers.
......... .........
Applican
This permit is issued for a well located as shown to the above named well driller in accordance with the Provisions of
Public Act 187 of the 1963 Session of the Connecticut Legislature this........./. day o
e � ;
WHITE—ISSUING AGENT !��' "J .. .. .. .......................... `I....................................................
GREEN—APPLICANT $7u,J,dtWy g yl�..
PINK—LOCAL HEALTH OFFICER
CANARY—WATER RESOURCES COMMISSION (Over)