HomeMy WebLinkAbout1983-4-7 - 1010 Avery Street - Well Drilling PermitCONSUMER PROTECTION
WELL DRILLING BOARD
CPR-B REV. jkB2r
LOCATION WEII
op
OWNER OF WELL
11 INDIVIDUAL
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
WELL DRILLING PERMIT
165 CAPITOL AVE., HARTFORD, CONNECTICUT 06106
BUILDER Al OTHER (Spec
PERMIT NUMBER
80629
DATE
.,S,/ -7- 83
OWNER'S ADDRESS
' -
-
' ' - T
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4G
BUSINESS
TEST
Est. No, of
PROPOSED
DOMESTIC
ESTABLISHMENT
FARM
k
WELL
People being -
USE OF
served.
WELL
PUBLK
SUPPLY
INDUSTRIAL
AIR
CONDITIONING
ER
((Specify)
-
E)
Indicate North
SKETCH OF WELL LOCATION
Locate well with respect to of least two roads, showing distance from intersection and front of lot
Location of lot to at least two roads
S
1k
w
GL
led
Well locotion on lot and to house (if present)
a
r00
:----�;
r
Approximate number of feet from well to
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 rot Stalutes must be sent to the owner, the Board and the Water Resources Commission on the form provided by the
Board. s permit B P61 VoIld wlij all 1nFo . n1s 'Land it has been counter -signed by the Director of Health or his agent
APPC rgxdr rcf APP11CANT'5 ADDR 55 REGISTRATION NO.
r - - BY {rowx Hralsk OJJrccr or nr� VAlt
APPROVED REJECTED iJee
REMARKS
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD