HomeMy WebLinkAboutWell New 00 Buckland Road (10) WELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
1ND84 1
1-69 WELL DRILLING PERMIT
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115 3906
LOCATION OF WEL
I(B)can) r (Sheet) (Lot Number) DAVE
OWNER OF WELL
❑ IN WOUAL 910'BUILDER ❑ OTHER(Specify)
OWNER`S ADDRESS \
PROPOSED BUSINESS TEST Est.No.of
12""DOMEST ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL ❑ OTHERPUBLIC AIR SUPPLYY ❑ 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 - •
�e2.
•1 •
• a
t
Approximate number of feet from well to A y�
nearest source of possible contamination:
.F
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 i led in and if has been hunter- ned by the Director of Health r s agen.
APP1k IS; APPLYO&MADDRE REGIS TI NO.
BY{Town. Bh Or AgeM) DATE
APPROVE ❑ REJECTED
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD