HomeMy WebLinkAboutWell New 00 Graham Road ,.WELLID ILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
NYDB4 11-69
WELL DRILLING PERMIT' 3267
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 06115
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LOCATION OF WELL(Town) (Street). (lot Number) DATE
�e
OWNER OF WELL
INDIVIDUAL BUILDER ❑ OTHER(Specify)
OWNER'S ADDRESS
-
PROPOSED BUSINESS TEST Est.No.of
D�OMESfIC
USE OF "ESTABLISHMENT El FARM ❑ yyEu People being
served.
PUBLIC AIR
WE%LL ❑ OTHER
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
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Approximate number of feet from well to 13—N
nearest source.of possible contamination: Cc)
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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 tilled in and it has been counter-signed by the Director of Health or his agent.
A PI aturel APPLIW Sj4DDRESS REGISTRATION NO.
BY(To ith O r or Agent) DATE
❑•APPROVi D ❑ REJECTED
REMARKS i
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD