HomeMy WebLinkAbout143 Oakland Road (2) CPR-8 Rev 7i95
PERMIT NUMBER
STATE OF CONNECTICUT 265313
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE&PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue,Hartford,Connecticut 06106
LOCATION OF WELL (Town) (Street) (Lot Number) DATE
South Windsor 1 4 i Oakland ?�?
OWNER OF WELL
aINDIVIDUAL BUILDER D OTHER(Specify)
OWNER S ADDRESS
Scott Simler 143 Oaklanry Rr Sot-it!, 'Ninr?sor
Est No of
PROPOSED x DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served
WELL
PUBLIC ❑ INDUSTRIAL D AIR OTHER
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 resent)
Indicate North 601
r
�CvrCC ,
Approximate number of feet from well to
nearest source of possible contamination 351 to sanitary s eWe r
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
APPLICANT(Signature) APPLICANT'S ADDRESS REGISTRATION NO
Joel St.avens 0 T pox 406 T�rillington 4?
BY(Town Health OI/icerorAgepQ DATE
❑ APPROVED REJECTEDX/1*0
REMARKS
DIRECTOR OF HEALTH