HomeMy WebLinkAboutWell Correspondence 116 Lisa Drive Vanguard Direct Rocky Hill,CT•VG#01-731575-1 11107 W-104280 T
CPR-8 Rev.7/95 PERMIT NUMBER
STATE OF CONNECTICUT RED► '
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION MAR 14.20.12
WELL DRILLING PERMIT souTH
165 Capitol Avenue,Hartford,Connecticut 06106 H L.-rH NDSOR
DEp
LOCATION OF WELL (Town) a (Street) (Lot Numher DATE
7/:'A- 0o:
OWNER OF WELL
INDIVIDUAL BUILDER OTHER(Specify)
OWNER'S ADDRESS
A CPA C
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL PUBLIC INDUSTRIAL CONDITIONING AIR OTHER
SUPPLY ���.�t
SKETCH OF WELL LOCATION Jam"-'
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 to and to house(if present)
Indicate North aV.
T
pre
e
w �
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"containing construction details and information required under
Section 25-131 of the 1969 Supplement to the General Statutes must be sent to the owner, the Department of Consumer Protection and the Water
Resources Commission on the form provided by the a c This per i is not valid Juntil all information is ff'illl9d in and it has been counter-signed by
the Director of Health or his agent.
APPLI gnature) APPLICANT'S ADDRESS Q�XT'E REGISTRATION NO.
B (Town Health Officer or Agent) DATE
APPROVED ❑ REJECTED
REMARKS
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