HomeMy WebLinkAboutWell New 911 Foster Street (2) DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
M >>-e9 WELL DRILLING PERMIT' 0905.
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 0#1156
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LOCATI OF WE L(Town) (Street) (Lot Number) DATE
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OWNER OF WELL
INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS CaIllw %_1/ 1007AE
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM WELL People being
USE OF served.
WELL PUBLIC AIR❑ UPP Y ❑ INDUSTRIAL ❑ CONDITIONING ❑CONOTHDITIONING (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
-00
Approximate number of feet from well to
nearest source 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 6 of
Public Act 659 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 informa-
tion is filled in and it has been counter-signed by the Director of Health or his agent.
APPLIC igna re) APPLICANT'S ADDRESS REGIST!RJ�IO:
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BY(To Health Officer or Agent) DATE
4PPROVED ❑ REJECTED 70
REMARKS
DIRECTOR OF HEALTH