HomeMy WebLinkAbout1972-8-14 - 150 Berle Road - Well Drilling ApplicationWELL DRILLING -BOARD STATE OF CONNECTICUT PERMIT NUMBER
WD" 11-69 WELL DRILLING PERMIT 11834
STATE OFFICE BUILDING, HARTFORD, CONNECTICUT 06115
67)
OWN& of EL1
riNDIVIDUAI
❑ BUILDER
❑ OTHER (Specify)
OWNER'S ADDRESS
PROPOSED
USE OF
WMESTIC
BUSINESS
El ESTABLISHMENT
❑ FARM
1EST
El WELL
Est. No. of
People being
served.
WELL
PUBLIC
❑ SUPPLY
❑ INDUSTRIAL
AIR
❑ CONDITIONING
❑ (STHER
pecify)
y
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
nearest source of possible contamination:
The undersigned is aware that upon eompfetian of the well, a "Well -Completion Report" containing construction details and information required under Section 25-131
of the 1 F69 Supplement to the General Stayes must be sent to the owner, the Board and the Water Resources Commission on the form provided by the Board. This
per it is not oljd until !information is filled in and it has been ant =si ned by the D__ irgctar of Health or his agent.
d7 �-, A.7�t _
A tJT (SignahnrJ AP 'DDRE55,�� REGfS N NO.
BY (Town Ht Ifh Offimr�w Agrn! DATE
❑ APPROVE) ❑ REJECTEq
r
RETURN THIS -COPY TO CONNEC'11CUT WELL DRILLING BOARD`