HomeMy WebLinkAboutWell New 173 Miller Road WELL DRILLING BOARD ' ' STATE OF CONNECTICUT PERMIT NUMBER
WDB-4 11-69 WELL DRILLING PERMIT 2153
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL(Town) (Street) (Lot Number) DATE /'
217 v
OWNER OF WELL
❑ INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No.of
❑ DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ PUBLIC AIR SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (STHER
pecify)
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)
InNorth
Z/2
4-.
-- ��
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. ^/
APPLICA (Signal APPLICANT'S ADDRESS REGISTRATION NO.
BY(To Health Offic4r or DATE
❑APPROVED ❑ REJECTED / 7 a
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD o.