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CPR-8 Rev.7J95 PERMIT NUMBER
9602 7
.
STATE OF CONNECTICUT 1
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106 .�
10CATION OF:WELL (Town), (Streetp (Lot Number) DATE {_
OWNER OF WELL
.INDIVIDUAL ;.1 BUILDER El OTHER(Specify)
_ . OWNER'S ADDRESS
A. �y // quo+ J_ pj/ 9y y,,,_
d'w7, W/ ;0.9-,� J"�®^a'f. O QOBI CT.q f 71I r Yf d�Y:.� O� e. Sv'•i:'�LJ h.J
Est.No.of
PROPOSED ® DOMESTIC BUSINESS FARM TEST People being !
USE OF ESTABLISHMENT WELL served.
WELL
PUBLIC O.THER.,. I
i .SUPP Y u a`'INDUS7RIRL. 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)
Indicate.North - +
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a
ar V,
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4
Approximate number of feet from well to s
nearest source of possible contamination: ` i
The undersigned is aware that upon completion of the well, a"Well Completion Report"containing construction details and information required under I
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-sighed by
' ahe Director of Health or his agent.
APP NT(Signature) APPLICANT'S ADDRESS�/�Isi'�avea 3 (ue„ p s t t,,`Ve s %fie_ REGISTRATION NO.
s
BY Town Hlth Officer or Age a DATE
APPROVED REJECTED-. ,'
REMARKS `�. -.
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DIRECTOR OF HEALTH