HomeMy WebLinkAbout559 Avery Street CPR-8 Rev.08/17
PERMIT NUMBER
STAT£``OF CONNECTICUT 267165
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE rll PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
450 Columbus Boulevard Suite 901, Hartford, Connecticut 06103
LOCATION OF WELL (Town) 1 � (Street) (LotNumDer) DATE
OWNER OF WELL11
INDIVIDUAL a BUILDER OTHER(Specify) —F.
OWNER'S ADDRESS vio Sc2
S` D StAivii Ave Sort t�, � o C; 0& L)
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL
SUPpLINDUSTRIAL AIR CONDITIONING OTHER
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)
vJt��
Indicate North
vho�s �a
�. ll
AVCe
1 - —
a
1
Approximate number of feet from well to
nearest source of possible contamination: <1 t b 0 U
The undersigned is aware that upon completion of the w1111, 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 T(Signatu ) APPLICANT'S ADDRESS REGISTRATION NO.
-Tz)il 67 oL® a"
BY 17own Health Officer or Agent) - DATE
�PPROVED 0 REJECTED
REMARKS
DIRECTOR OF HEALTH