HomeMy WebLinkAbout744 Sullivan Avenue PERMIT NUMBER
CPR-8 Rev.08)17
2.67168
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILiLINC PERMIT
450 Columbus Boulevard Suite 901, Hartford, Connecticut 06103
LOCATION OF WELL (Town) (Street) (Lot Number) DATE
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OWNER OF WELL
INDIVIDUAL a BUILDER OTHER(Specify) —ram
OWNER'S ADDRESS �Ja
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Est.No.of
PROPOSED DOMESTIC El BUSINESS FARM � TEST People being
USE OF ESTABLISHMENT WELL served.
WELL
PUBLIC 1:1SUPP Y 1:1 El INDUSTRIAL AIR CONDITIONING STpeHGERI
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)
Indicate North
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1
2
Sv��;v��•, �arc.
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
j Resources Commission on the form provided by the agency. This permit is not valid until all information is filledin and it has been counter-signed by
the Director of Health or his agent.
AP LICANT(Sign ) APPLICANTS ADDRESS
1 REGISTRATION NO.
To 4.j
BY ffown Health Officer or Agent) DATE
" - APPROVED ❑ REJECTED Q
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REMARKS
t
DIRECTOR OF HEALTH