HomeMy WebLinkAboutVariance 785 Foster Street STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
DRINKING WATER SECTION
APPLICATION FOR WELL PERMIT EXCEPTION PURSUANT TO SECTION 19-13-B51 M OF THE
REGULATIONS OF CONNECTICUT STATE AGENCIES
The Regulations Of Connecticut State Agencies (RCSA), Section 19-13-B51m(b) prohibits a local director of
health from issuing a well drilling permit at residential premises where the water will be used for human
consumption, or at non-residential premises where the water may be used for human consumption, when a
community water system is deemed available within two hundred feet, measured along a street, alley or
easement from the parcel's boundary. In some circumstances, pursuant to RCSA Section 19-13-B51m(c) an
exception may be granted to the above mentioned section.
To apply for an exception, the applicant shall complete Section #1 of this application and have the water
company complete Section #2 on the second page. Then the local health department, upon a preliminary
review of the application shall complete Section #3. The completed application may be emailed to
DPH.SourceProlection(a-cl.gov or it maybe mailed to the following address:
Department of Public Health
Drinking Water Section, Source Assessment and Protection Unit
410 Capitol Avenue MS#51 WAT
P O Box 3403038
Hartford, CT 06134-0308
1.Well Applicant Information:
Property Address: 772rS _VZ&+154, JT_EF2&�
Applicant Name and Address:—3;zt, w WaX\S lim Aji s st 3•"".Ste
Type of property: single-family residential
residential
commercial
Provide all reasons that may justify the well permit exception request, particularly construction problems.
Supporting documentation must be submitted along with the justification.Attach additional pages if
necessary.
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Signature of well ant DATE
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Rev 2/16
2.Community Public Water System (CPWS)available within 200 feet from the property line
CPWS Name and ID: n " �
Cogr�ecr�cHf t�(/r4rc� (� (✓-s�crnl - CT o y730/�
Is the property in discussion currently served by the CPWS? Yes❑ No
If yes,be aware of the cross-connection protection requirements.
Will an exception, if granted,adversely affect the purity and adequacy of the CPWS
water supply, or the service to the customers of the CPWS? Yes❑ No
Is the CPWS able to provide adequate water supply service as requested by
the owner of the property located within their exclusive service area boundaries? Yes pl' No❑
If no, all reasons and factors that prevent the CPWS from serving the property must be included.Attach
an additional letter with the explanation. Also indicate whether additional supply, storage and booster
facilities are necessary for providing proper service.
Does the CPWS recommend the issuance of the well permit exetion? Yes 0' No❑
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Sign a of CPWS inistratl a Offic' I or Certified Operator: [SATE
f3. Local Health Department(LHD)with jurisdiction over the property:
Sow w�V-\ �
Can a well be located on the property pursuant to RCSA Section 19-13-B51d? Yes& No❑
Is there any known particular concern with water quality or quantity in the area? Yes❑ No[�
Indicate of type of sewage disposal proposed: Septic system❑ Sewer 11
Is the lot in discussion part of a subdivision? Yes❑ No L
Does the LHD recommend th issuance of the well permit exception? 1'es u' No❑
Signature of Loca clot Health DATE
For additional information or questions regarding this application,please contact the Drinking Water Section at(860)509-7333
Drinking Water Section Use Only
Received Date: _ Closed Date:
Application complete: Yes❑ No❑
Assigned Staff Person Approved ❑ Denied ❑
DPH Project Number:
2 of
Rev.2/16