HomeMy WebLinkAbout395 Buckland Road PERMIT NUMBER
CPR-8 Rev.08/17
STATE OF CONNECTICUT 267160
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING:PERMIT
450 Columbus Boulevard Suite 901, Hartford, Connecticut 06103
LOCATION
++OF dWELL (Town) (st-0 (Lot Number) DATE
�3Uv1T� W,v15ifZ J95 dtALlCfonGr) r )�'
OWNER OF WELL
INDIVIDUAL a BUILDER OTHER(Specify)
LL
OWNER'S ADDRESS �r {`;t Q t.as �v p M'✓t 'L; y � V V t rl:. l�7 tC C 9 `� 10 1 5
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being 1:1USE OF ESTABLISHMENT WELL served.
WELL
PUBLIC 1:1
SUPPLY INDUSTRIAL CONDITIONING OTHER AIR 1:1 p
SKETCH OF WELL LOCATION f
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)
i A it tt *A,A lip Al
V,),t I
Indicate North
ROCgLAIOD
CV(k
i
I
ko S wt-
Approximate number of feet from wellto
nearest source of possible contamination:
-a 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
I, the Director of Health or his agent.
t APPL T(Signatu APPLICANT'S ADDRESS REGISTRATION NO.
BY(Tpwn Health Officer or Agent) DATE
0,1APPROVED REJECTED II
i; REMARKS
i
RECEIVED
SEP 19 2018
SOUTHVNNDSOR
HEALTH DEPT.
DIRECTOR OF HEALTH