HomeMy WebLinkAboutWell 825 Clark I
PERMIT NUMBER
CPR-8 Rev.7/96
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STATE OF CONNECTICUT
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DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Conn&ticut 06106
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LOCATION OF WELL (Town) (Streeq (Lot Number) DATE
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�.. �'s-141
OWNER OF WELL
.INDIVIDUAL BUILDER OTHER(Specify)
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OWNER'S ADDRESS
Est.No.of
PROPOSED a DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served. ;
WELL 5 C{J a %✓ .
a PUBLIC a INDUSTRIAL ❑ AIR OTHER (t -
t SUPPLY CONDITIONING S eoi y i
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) j
l Indicate North
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Approximate number of feet from well to ;- ; .<
nearest source of possible contamination: r' y u f- ` ='f
s 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. (. f.`.t ;i_ `�Z cw'i
APPLICOP(Signsture) APPLICANT'S ADDRESS - > REGISTRATION NO.
z, J BY(down Health OfficerorAgent) DATE
APPROVED REJECTEDn,
REMARKS
RECEIVED
10
SOUTH WINDSOR
HEALTH DEPT.
DIRECTOR OF HEALTH j