HomeMy WebLinkAboutWell 356 Long Hill Road CPR-8 Rev.7/95 PERMIT NUMBER
WIGSTATE OF GONHECTICUT
DEPARTMENT;OFCONSUMER.PROTEGTION ..
} :REAL ESTATE 8i PROFESSIONAL TRApES DIVISEQH
OCT < _
WELL BII Jr PERIKIT 8 20#4-.
: 165 Ca pitol Avei►ue�Hartlicsrd,Connecticut 06106 SOUTH WINDSDR
=LOCATION OF WELL jTown) (Sliest) � (lot Number)` DATE
Saute. �it±dsor 356 1kopq full R4. 10f24/1
OWNER OF WELL _ y
INDIVIDUAL a BUILDER a Contractor
OTHER pey)
OWNER'S ADDRESS
Craig' aplan PO Box 465` Broad Brook
PROPOSED - a DOMESTIC BUSINESS FARM Q TEST' PEst.No.of
USE OF ESTABLISHMENT eople being
WELL 1NELL. served.
SUPPLY INDUSTRIAL_ -CONbITIONING a ,AIR
STHER _
SKETCH OF.WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of lot
location of lotto atteast two roads Well location onto and to,house(if present)
Indicate.North
QV
-`tD
Approximate number of feet from well to r
nearest source of possible contamination:
The undersigned is aware that upon completion of the well,a 'Well Completion Report containing construction details andanformation 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
Resource ^ommission 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 D.i - or o alth or his agent.
APignaf APPLICAN`rS ADDRESS - REDISTRA TION NO
gel Si~av� ;s O : ox 06 W 11 c to
8Y(Towtt Heald►O cer pr Agent) - DATE
APFROVEfl REJECTED
$ 4Na—
REMARKS
_A
i
DIRECTOR OF HEALTH