HomeMy WebLinkAboutWell New 00 Niederwerfer Road WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
wD64 11-69 WELL DRILLING PERMIT 20271
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06715
LOCATION OF WELL (Town) (Street) (L-oot umber) DATE
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OWNER OF WELL
INDIVIDUAL UILDER OTHER(Specify)
OWNER'S ADDRESS `/ !
6-0
PROPOSED BUSINESS TEST Est.No.of
DOMESTIC ❑ ESTABLISHMENT ❑ FARM WELL People being
USE OF served.
WELL PUBLIC 1:1ER SUPP Y INDUSTRIAL ❑ CONDITIONING (Specify)AIR 1
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,
5
e, Ile ,
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
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.
APPLICANT(Signature) APPLICANT'S ADDRESS/ l d O 6 6 REGISTRATION NO.
7q f e u 7folll fe!
own H OfJzcer or dgent DATE
A PROVED EJ REJECTED I I !O 30 73
REMARKS
DIRECTOR OF HEALTH