HomeMy WebLinkAboutWell Abandond 268 Nevers Road 12/03/2012 MON 15:06 FAX 210 349 2464 ERCC OFFICE 0001
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*** FAX TX REPORT ***
TRANSMISSION OK
JOB NO. 4430
DESTINATION ADDRESS 918604295158
PSWD/SUBADDRESS
DESTINATION ID
ST. TIME 12/03 15:05
USAGE T 00' 21
PGS. 2
RESULT OK
1540 SuNivan Avenue
South Windsor,CT 06074 South Windsor
Ph: 860-644-2511 ext.248
Fax: 860444-7280 Health Department
• .
Fax
To: Stavens Bros Water Wells From: Sheny McGann
Fam 860-429-5158 Pages: 2
Phimm 860-429-429-1740 Date: 12/3/2012
Re: Well Location Information—268 Nevers CC:
Road,South Windsor,CT
❑urgent 0 For Review ❑Please Comment ❑Please Reply ❑Please Recycle
•Comments:
CPR-8 Rev.7/95 PERMIT NUM(�BEER
STATE OF CONNECTICUT 25 3 7 6 V
DEPARTMENT OF CONSUMER PROTECTION
yr REAL ESTATE&PROFESSIONAL TRADES DIVISION
�1a 165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL_ (Town) (Street) (Lot Number) DATE
South Windsor 263 Nevers Rd 12/4/12
OWNER OF WELL
® INDIVIDUAL BUILDER OTHER(Specify)
OWNER'S ADDRESS
John parkins 39 Stonehenge Ln nolton
Est.No.of
PROPOSED DOMESTIC BUSINESS El FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL
PUBLIC _ w ; INDUSTRIAL--_ AIR ,,El �� ., ,,Q <OTHER,WELT:, ?�lR ATTOONMFNT
SUPPLY 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 to and to house(if present)
Indicate North
101,
AA
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 agency. This permit is not valid until all information is filled in and it has been counter-signed by
the DinegWr of Health or his agent.
APP NT IS ) APPLICANT'S ADDRESS REGISTRATI N NO.
Joel Stavens PO Box 406 Willington 49
BY(Town Ith Of/icerorAgent) DATE
APPROVED - REJECTED �, � � r-�
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REMARKS
DIRECTOR OF HEALTH
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