HomeMy WebLinkAbout1020 Strong Road i
PERMIT NUMBER
CPR-8 Rev.08/17
266334
STATE OF FONNECTICUT,
DEPARTMENT OF CONSUMER PROTECTION
'REAL
ESTATE 8t PRIOF StiIONAL TRADES DIVISION
WELL DR14ING PERMIT
450 Columbus Boulevard-Suiite.I9t 1, Hartford, Connecticut 06103
LOCATION OF WELL (Town) (St-0 (Lot Number) BATE 1
CV vV%yr�SG f C�cJC Ao" G� R t d Y
OWNER OF WELL
INDIVIDUAL BUILDER OTHER(Specify) lov,C 4,v.ra---7
OWNER'S ADDRESS
11 -7 r
1I Est No.of
PROPOSED s DOMESTIC : ,BUSINESS.,. FARM El ,EST, ry .People being
USE OF ESTABLISHMENT $ WELL served.
WELL
1 Q PUBLIC a INDUSTRIAL a AIR OTHER
I 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)
I �
'Indicete NorNti:. .' .
(( t
o
r
F01
j
Approximate number of feet from well to
nearest source of possible contamination: 7S
The undersigned is aware that upon completion of the well,a"Well Completion Report"containing construction details and information required order
Section 25431,of ttie 1969 Supplerilent 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. Thisperrnit is not valid until all information is filled in and it has been counter-signed by
the Director of Head or=his ei t. _L, Lva t°� ( ��1 f L
APPUCAN (Signatwe} ( awry+�:: - A -PkiCANT'S". ErSS REGISTRATION NO
rt ,y
/ BY Town Health fficer or Agent) DATE
[TJ�APPROVED ❑ REJECTED ' p �-I
REMARKS ff I
k�sf` k�t?Ii%'��c�{ �?/c�sh7 q �oVF 4elP rO �vr � �C/Yt?�,� (� e jc� t�r<'��°' S
DIRECTOR OF HEALTH