HomeMy WebLinkAboutWell New 1010 Strong Road (2) TOWN OF -SOlaTf WINDSOR
• - 51 South Wink " , � �..►-
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� sor, Bonn Date .. ...... ...... ............................... ..............
L ]DRILL WS PERMIT
A
............. ..... , of the fi of......... . i...
................ . ........ .............................................. ...... (address) . -
hereby state that I (we) am (are) a well ri er du y and currently egistered with tate of Con ticut Water Resources
Commission and do make application herewith for a W Driller's P it accordance with the provisions of Public Act 187
of the 1968 Session of the Conn tic Le 1 ure, a well to d 11 n the property of:
Name of Property Owner:............. ,... ...........
' -
................ . ......
Address of Property Owner:..............
....
Address of Premises o ich well is located:.......... .
......................... ..... ...
The approximate lot�o of the well will be as shown,on the reverse side of this permit.
The undersigned is aw t upon completion of this well the above data,together with a well log of information required
under (c) and (d) of Public 7 of the 196 Session must be sent to: Water Resources Co sign, 223 State Office
Building, Hartford, Connecticu a form entitled"Well Completio port"which ha
jAgn surAieh to registere fillers.
�' ►e"
Applicant
This permit is,issued for a well loca s shown to the above named well driller in accordan with the Provisions of
Public Act 187 of the 1963 Session of the Connecticut Legisla re t is....... a of....... ......... ..
...........,196..........
WHITE—ISSUING AGENT lr.... �'
GREEN—APPLICANT
PINK—LOCAL HEALTH OFFICER B 'ldiny Offici or Tow erk
CANARY—WATER RESOURCES COMMISSION (OVer)
Location of Well: Town of....� ...t....,.. ............t...... .............. ... -�`.`...............
SKETCH SHOWING LOCATION OF PREMISES IN TOWN
.(Show distance and direction from road intersection or other la dmark)
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Diagram Showing Location of Well on Premises:
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Route Directions for Reaching Well Site from Nearest City or Village Center: