HomeMy WebLinkAbout45 Gerber Road East CPR-8 Rev 7)95
PERMIT NUMBER
STATE OF CONNECTICUT `" `•' 5 9
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
MON WELL DRILLING PERMIT
185 Capitol Avenue Hag1ord,Connecticut 06106 `
LOCATION OF WELL (Town) (Streer) (Lot N 0 DATE
i
OWNER OF WELL
INDIVIDUAL BUILDER OTHER(Specify)
OWNER'S ADDRESS
Est No of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served
WELL
0 PUBLIC SUPPLY INDUSTRIAL AIR CONDITIONING (Spec y)
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)
Yj
Indicate North yri.Cit.
�4 � i
i
$9
�
41
90Wzivt
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I
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 Director of Health or his agent
APPLI ANT jStpnature) ./ APPLICANT'S ADDRESS �J h REGISTRATION NO
/ /' /
z, 1 — - " j. Ai A/ �7 , 1; r>�
BY(Town Health Officer otApent) DATE 1
❑ APPROVED ❑ REJECTED
in , )4
REMARKS
DIRECTOR OF HEALTH