HomeMy WebLinkAboutSeptic New 425 Foster Street a
' TOWN OF SOUTH WINDSOIi
No South Whidsor, Conn.
® 1 Date ........�... ._.�../".,[-:;...:. ............. ,
WELL DRILLER'S PERMIT �
:...................... of the firm of...../.. /late
� Z. .c .. .......... ............. (address) . �. 4hereb state that I we am y y gy ( ) ( ) a well driller dul and currentl re istered with the' f 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 wel,) to be drilled on the property of:
Name of Property Owner:.... ... =
Address of Property Owner:....... .... .... Dk
..... .... ..........................................:...................
Address of Premises on which well is located:................. 14.110
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The approximate location of the well will he as shown on the reverse side of this permit. 4r lc� r
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 Comple o "whiSh has been supplied to stered drillers.
-: ... ... .
p ica Apint
This permit is issued for a well located as shown to the above named well driller in accordant with the Provisions of
Public Act 187 of the 1963 Session of the Connecticut Legislature this......... . 7 //
day of.... .D...!✓. Tl�t. !8...., 196..0..
WHITE—ISSUING AGENT
GREEN—APPLICANT ....................................................................................................... .. ..
PINK—LOCAL HEALTH OFFICER Building Official or Town Clerk
CANARY—WATER RESOURCES COMMISSION (Over)
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Location of Well: Town ol........':I ........... ..:........
SKETCH SHOWING LOCATION OF PREMISES IN TOWN
(Show distance and direction from road intersection or other landmark)
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Diagram Showing Location of Well on Premises:
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Route Directions for Reaching Well Site from Nearest City or Village Center:
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