HomeMy WebLinkAboutWell 530 Buckland Road � NUMBER
CPR-8 Rev.7/95
STATE OF CONNECTICUT
y� DEPARTMENT OF CONSUMER PROTECTION Nov "
9e REAL ESTATE&PROFESSIONAL TRADES DIVISION 1 ?171Z
�DUTH Wi
WELL DRILLING PERMIT H NDSO
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL (Town) (Street) (Lot Number) DATE
South Windsor 530 Buckland Rd 11 /27/12
OWNER OF WELL
INDIVIDUAL a BUILDER OTHER(Specify)
OWNER'S ADDRESS
Standard Demolition 30 Nutmeg Or Trumbull
Est.No.of
PROPOSED DOMESTIC BUSINESS El FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL
aPUBLIC a INDUSTRIAL AIR a OTHER TgvTjL A13 1`TOOMMENT
SUPPLY El 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)
pole. oa, \ R
0 �tA
4 (Pche,
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Indicate North Dot )OS
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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 Direo6r gWealth or his agent.
APPL ignatu APPLICANT'S ADDRESS REGI TRATION NO.
Joel Stavens PO Rox 406 `Millington 2
BY(7' Health Officer or g (it) a DATE
APPROVED REJECTED � l
REMARKS
DIRECTOR OF HEALTH