HomeMy WebLinkAbout1972-9-19 - 118 Berle Road - Well Drilling ApplicationWELL DRIIIJNG BOARD
WD" 11-69
STATE OF CQNNECIICUT
WELL DRILLW PERMIT
STATE OFRCE BUILDING, HARTFORD, CONNECTICUT 06115
OWNER OF WELL
❑ INDIVIDUAL
BUILDER
' " —
❑ OTHER (SpedW
- �� --A,
GARLO PRESTILEO
OWNER'S ADDRESS
_
59
ASH ROAD,
WAPPING,
CONIC.
PROPOSED
USE OF
®
DOMESTIC
BUSINESS
❑ ESTABLISHMENT
❑ TEST
❑ FARM U
WELL
❑
PUBLIC -
SUOTHER
PPLY❑
INDUSTRIAL
AIR
❑ CONDITIONING ❑ (Spa-ify)
— _
SKETCH OF WELL LOCATION
— _
Locate well with
resped to at least two roads, showing distance from intersection and front of lot
0
Indicate North
PERMIT NUMBER
12601
9/19/?2
Location of lot to at least two roads IWell location on lot and to house {if present)
P411!
Est. No. of
People being
served.
Approximate number of feet from well to
nearest source of possible contamination: _ ! A N m
The undersigned is aware that upon comp] 'an of the well, a "Well Completion Report" containing construction detailsarid ininf-orrmation required under Section 25-131
of the 1969 Supplement to the General t lutes must be sent to the owner, the Board and the Water Resources Commission on the form provided by the Board. This
permit is not valid until all information i led in and it has been counter -signed by the Director of Health or his agent.
APP NT ignalu - APPUCANT'S ADDRESS REGISTRATION NO.
T.bVV. QM t7
BY [Tnwn rrr or tl DATE
® APPROVED REJECTED / � 7`f�—
REMARKS -
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD