HomeMy WebLinkAbout1984-4-30 - 165 Berle Road - Well Drilling Applicationa
CONSUMER PROTECTION
` WELL DRILLING BOARD
CPR-8 REV. 11-82
LOCATION OF WELL CTn-n]
S. WIIIDSOR
STki• OF CONNb--- TICUT
DEPARTMENT OF CONSUMER PROTECTION
WELL DRILLING PERMIT
165 CAPITOL AVE.; HARTFORD, CONNECTICUT 06106
CS—*
165 BERLE RD.
PERMIT NUMBER
86541
4/30/84
OWNER OF WELL
INDIVIDUAL
BUILDER
OTHER (Specify)
AIIGMA
iVEGRON & STEPBMI GRAUSMSKI
OWNER'S ADDRESS
398
igEVERS ROAD,
S. V110SOR, CT.
644=0175 or
565-2248
PROPOSED
j
'BUSINESS
r�
TEST
Est. No. of
I DOMESTIC
LJ ESTABLISHMENT
LJ FAQ
WELL
People being
USE OF
served.
WELL
PUBLIC
SUPPLY
L, INDUSTRIAL
AIR
CONDITIONING
OTHER
(Specify)
4
SKETCH OF WELL LOCATION
Locate well with respect to at least two roods, showing distance from Intersecilon and front of lot
Indicate North
Location of lot to at least two roads I Well location on lot and to house (if present)
17 Dw,
/
raE<! f zv
4'
GCEA Ro
Approximate number of feet from well to
nearest source of possible contamination: 1001
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 Board and the Water Resources Commission on the form provided by the
Board. This permit is not valid until all information is filled in and it has been counter -signed by the Diiector of Health or his agent.
AP NT (SrBrwrureJ APPLICANT'S ADDRESS REGISTRATION NO.
P.O. BOX 111, S. WILLIIdGTOiV , CT . 100
—� BY (Ibwn Heelib Officer or Agent DATE
®'*APPROVED REJECTED 2
REMARKS
W. 4
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD