HomeMy WebLinkAboutWell New 330 Governor's Highway G 4/1, 1���PERMIT
NUMBER
CPR-8 FiCv.7/95 ` dfvSTATEOFCO. ECTICUTo! 17 el 4 5
DEPARTMENT OF CONSUME PRO CD Q fir'R TEC� .,
REAL ESTATE&PROFESSIONAL TRADES DIVI�O�I
WELL DRILLING PERMIT �lF�,
165 Capitol Avenue,Hartford,Connecticut 06I06 Ink _
LOCATION OF WELL (Town) (Street) (Lot Number) / OATS
' 33 CJ 0 � r�U �L,. W r t/l.!/S.dL"'. Ci( 4 L
OWNER OF WELL
INDIVIDUAL. BUILDER ® OTHER(Specify) U Y'G"
/-
OWNER'S ADDRESS
�`1[ �� / �^)� //�./�tlto w� ��((1111, Ca / �
vl�'�t(�o �
Est.No.of
PROPOSED DOMESTIC � BUSINESS � FARM ® TEST y People being
USE OF ESTABLISHMENT WELL ` served.
WELL PUBLIC ,
SUPPLY INDUSTRIAL AR CONDITIONING BTHeER
SKETCH OF WELL LOCATION J�
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 to and to house(if present)
Indicate North AIA,
� c
� Fvr�l
Approximate number of feet from well to /v,
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 25-131 of the 1969 Supplement to the General Statutes must be sent to the owner,the Department of Consumer Protection and the Water
Resources Commission on the form provided by the agency. 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.
APPLICANT(Signna&m) APPLICANTS ADDRESS p/I/ ✓ G`, REGISTRATION NO.
t l ��iCl K�GCiCS! rl ve � 0661W 73
BY(Town Health Officer or Agent) DATE
PROVED ❑ REJECTED R- V
REMARKS
for C 1%A trot,,VVfl✓"C�� �frSSGs�v+--a�`�
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION