HomeMy WebLinkAbout143 Oakland Road CPR-8 Rev 7/95
PERMIT NUMBER
STATE OF CONNECTICUT 265313
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
"••��� -= WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL (Town) (Street) (Lot Number) DATE
South Winidsor 143 Oakland 7f? 9/17/17
OWNER OF WELL
EINDIVIDUAL a BUILDER OTHER(Specify)
OWNER'S ADDRESS
Scott Simler 143 Oakland RM. South rNindsor
Est No of
PROPOSED x DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served
WELL
PUBLIC INDUSTRIAL AIR OTHER A
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)
(D 0
Indicate North 601
+� t� Tp C'/'t'12- r
ll�e l l l 11 e,
�C yr CC 1�
4_
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
APPLICANT(Signature) j / APPLICANT'S ADDRESS REGISTRATION NO
Joel Stavens f10 Rox 40 4?
BY(Town Health Officer orAge Q DATE
APPROVED REJECTED
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REMARKS
DIRECTOR OF HEALTH