HomeMy WebLinkAbout1536 Main Street (2) CPR-8 Rev.7/95 PERMIT NUMBER
265562
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
--/f 16¢Capitol/�yenue,Hart �onne ticut 06106
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LOCATION OF WELL (Town) ( ) (Lot Number) DATE
ram'
OWNER OF WELL
INDIVIDUAL BUILDER OTHER(Specify)
OWNER'S ADDRESS
Est.No.of
PROPOSED DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL
PUBLIC ,.UPPLY ElII INDUSTRIAL CONDITIONINGAIR OTHER;.. u
SKETCH OF WELL LgCATION
Locate well with respect to at least two roads,showin 'stance from intersection and front of lot
location of lot to at least two roads Well location on to and 12 house(if resent)
Indicate North
t
Ern
I
I � l
r
Approximate number of feet from well to t r
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
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 NT nature �s / APPLICANTS ADDRESS L{"i REGISTRATIO NO.
V8 ! t7 / r
BY(Town HeSIM Ofncer-orAgent) DATE
.APPROVED REJECTED
REMARKS
DIRECTOR OF HEALTH