HomeMy WebLinkAboutWell New 188 Smith Street WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER'>
WD" 11,69
WELL DRILLING PERMIT 213371
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
V � A
° + 1 ST
LOCATION OF WELL (Town) (Street)
(Lot Number) I DATE
OWMER OF WELL_
` Q INDIVIDUAL ❑ BUILDER OTHER(Specify)
(A7WV;nS DRES,S� J '
cc A, 11A Fa *-icj
PROPOSED BUSINESS
-� ® DOMESTIC ❑ FARM TEST Est.No.of
USE OF ESTABLISHMENT ❑ ❑ WELL People being
WELL ❑ PUBLIC AIR OTHER served.
SUPPLY INDUSTRIAL ❑ CONDITIONING ❑ (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
t _
V `
l
l
Approximate number of feet from well to a.
nearest source of possible contamination: Qr
The undersigned is aware that upon completion of the well,a"Well Completion Report' containing construction details and information required under Section
5-T31 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
oard. is permit is alid until inf rmation is filled in and it h n counter-signed b the Director of Healt or agen
17- D
APPLICANT(Signature) I APFLicANTIS ADDRESS '
I REGISTg�TION NO.
BY ow SealEle er or Agent) 7
DAT@ rr
APPROVED ❑ REJECTED
REMARKS
.r'
DIRECTOR OF HEALTH