HomeMy WebLinkAbout118 Troy Road CPR-8 Rev 7/95 1MBEER
STATE OF CON! \ 17 8
"a DEPARTMENT OF CONSI
REAL ESTATE&PROFESSIC `
WELL DRILLIII
165 Capitol Avenue,Hartfot "
LOCATION OF WELL (Town) (Street) (Lot Nu
1rov Vic' 7
OWNER OF WELL
ElINDIVIDUAL BUILDER
OWNER'S ADDRESS
t No of
PROPOSED y DOMESTIC BUSINESS pie being
USE OF ESTABLISHMENT erved
WELL
SUPPLY INDUSTRIAL CONDITIONING U {SpecifyPUBLIC ) d
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)
4 `
Indicate North
\ o°
U
e
i
Approximate number of feet from well to
nearest source of possible contamination.
F'li to Saf.lt: iiY 6:21ier
The undersigned is aware that upon completion of the well, a "Well Completion Report"containing construction details and information required under
Section 25o131 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 Dir 'or f b alth or his agent.
APPL Af(T nar ) APPLICANT'S ADDRESS REGISTRATION NO
%! BY(,Town Heafth Ofter or,4 nt) DATE
❑ APPROVED a REJECTED
REMARKS
DIRECTOR OF HEALTH