HomeMy WebLinkAboutWell New 1407 Sullivan Avenue WELL DRILLING BOARD STATE OF CONNECTICUT PERM1r NUMBER
WDB-4 11-69 WELL DRILLING PERMIT 3907
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
LOCATION OF ELL(Town) 1 (Street) (Lot Number) _]_DATE_
5u.��l R AtiNtt�f ¢ tom; 6 7
OWNER OF WELL +
® INDIVIDUAL ❑ BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
PROPOSED BUSINESS TEST Est.No,of
❑ DOMESTIC ❑ ESTABLISHMENT ❑ FARM
USE OF ❑ WELL People being
served.
WELL PUBLIC AIR❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ OTHER
(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
i�
-17
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 ntaining construction details and information required under Section 6 of
Public Act 659 must be sent to the owner,the Board and the Water Resources Commis i 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 ignature) t A LIC NT' DRESS f
REGISTRATF P.
w-�'
(i w Hea fficer nf) DATE
APPROVED ❑ REJECTED 6 /
REMARKS
DIRECTOR OF HEALTH