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HomeMy WebLinkAboutWell New 00 Foster Street w' .3L WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER V'NDR4 11-6' WELL DRILLING PERMIT 21883 STATE OFFICEBUILDING,HARTFORD,CONNECTICUT 06115 0- LQ /LOF W E LL (Town) (Street) (Lot Number) IATE OWNER OF WEL ❑ INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify) OWNER'S ADDRESS PROPOSED BUSINESS TEST Est.No.of DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being USE OF PUBLIC AIR OTHER served. WELL ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify) SKETCH OF WELL LOCATION Locate well with respect to at least two roads,showing distance from intersection and front of lot Location of lot to at least two roads Well location on lot and to house(if present) Indicate North (/V O l�3. Approximate number of feet from well to / nearest source of possible contamination: / 6 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 provided by 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) I APPLICA�DRZ REGISTRATION NO. � ice© n Health Oer or Agent):�PPROVED ❑ REJECTED DATE�Ch7 � r r 0 REMARKS DIRECTOR OF HEALTH