HomeMy WebLinkAboutWell 437 Clark Street CPR-8 Rev.7t95 PERMIT NUMBER
STATE OF CONNECTICUT 252363
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
B5 C itQ,1-Avenu Hartfgr Connecticut 06i06.
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a:. LOCATIONQF WELL !Town) ;;.. (Street) ::. .. tLotNumbei) rDA
'.INDIVIDUAL BUILDER
BUILDER OTHER(Specify)
OWNER'S ADDRESS
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Est.No.of
PROPOSED DOMESTIC BUSINESS FARM �; TEST People being
USE OF ESTABLISHMENT WELL- served.
WELL . ....:. ...
PUBLIC
AIR
SUPPLY INDUSTRIAL El CONDITIONING ❑ OTeER(Sp -
ow
SKETCH OF WELL LOCATION
Locate well with•respect to at least two.roads,.showing distance from intersection and
.front ofilot .
location of lotto at least two roads Well location on to and to house(if present)
Indicate North
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S1i�.1 t_ e gyp
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Approximate number of feet from well to I nI .
nearest source of possible contamination:
The undersigned is aware that upon completion of the well, a "Well Completion Report"cont.aming construction details and:information required under
Section 25-131 of the 1969 Suppl ent to the General Statutes must be sent to the.owner the 4epartmenf Of Consumer Protection and the Water
Resources Commission on the for provid d, a ency. This permit is not valid until all informa...tlon Is filled In and it has been'counter-signed by
the Director of Health or his agent,. 1)--
APPLICANT(Signature) ki APPLICANT'S ADDRESSS REGISTLtA'TI``ON NO.
5 a.,Ia v; P.-1,.13*4i76404tii /
own, Officer orAgent): DATE
' APPROVED REJECTED
r REMARKS t .
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DIRECTOR OF HEALTH
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: 30
BUILDING ADDRESS
STREET : c-
SUBDIVISION:
NORTH ARROW
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CONTRACTOR (PRINT) NAME OF CONTRACTOR'S SUPERVISOR (PRINT) ►-Ml�
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STREET AQDRESS SIGNATURE
TOWN STATE ZIP INSPECTED BY TOWN
% 6 0 / (",, / Lift
DATE
TELEPHONE: NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW - CONSULTING ENGINEER / DEVELOPER
STATE OF,CQNNECTICUT * DFPARTMFNT OF CONSCJMER PROTECTION
I Be:it known that
JOSFPH FP' L TII
69.1�ICB UDE RD
MON501�T, MA. 010579G8G
as:l eeri,cextifi�,d by tfie Depaxtxaent of Cp $umer.Prot c'ion as.a .
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WA 'F:R:SPY'CO CT
R+eg�sfi.f�ratoxi # . 000030W1
Effective: Q5�;10�/2015
Era t�oM: 04130j, 41G
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