HomeMy WebLinkAboutWell New 00 Pierce Road '. r� ♦' ` P,
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wDg.-a >> 6- 7- ` WELL DRILLING PERMIT I J 0 3
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF WELL n) t)` (Lot Number) DATE i
lion �
NER OF WELL
INDIVIDUAL ❑ BUILDER ❑ OTHER(Speci 1,/�
OWNER'S,,� � / r
Ayl `
PROPOSED BUSINESS TEST Est.No.of _
DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL ' Peo emg
USE OF rved.
PUBLIC AIR OTHER
WELL ❑ SUPPLY Y INDUSTRIAL ❑ CONDITIONING ❑ (SP-ify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection''and front of lot
�.. 1.94ion Qf lot to at,least two roads . .- , _ aNell:lol 00n gnaot andto house,((,present
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Indicate N rtg,
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Approximate number of feet from well to j
nearest source of possible.contamination: I
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. -
APPL�iqtwe) e. APPLI ANT�'S/ADDRESS RF�GISTRATION NO.
7. 'et LA:-.-P oN �dl+l L► . 140
BY o Health O er or gent) ^ o DATE
❑APPROVED ❑ REJECTED �
REMARKS
DIRECTOR OF HEALTH
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