HomeMy WebLinkAbout1999-11-10 - 17 Brookfield Street - Well Drilling Permit1999
PERMIT NUMBER
CPR-8 Rev. 7195
1971 Rn
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE & PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue, Hartford, Connecticut 06106 LOCA t L kl,NRJsd /e 7r-0t4--'1d__rAOL r) 17 DA 9ouI • ,--46?-9
p
7
EWELL
/;VNDIVIDUAL ❑BUILDER OTHER (Specify)
OWNER'S ADDRESS 1-2 �'node_&_ S_z . n- �
���]]] J Est No of
PROPOSED �OMESTIC El BUSINESS El FARM TEST People being
USE OF ESTABLISHMENT VVELL served.
WELL
SUPPLY INDUSTRIAL AIR El CONDITIONING STHER
PUBLIC 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 I Well location on to and to house (if Dresent)•
4
Indicate North
rlkof^ Ave -
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is aware that upon com
Section 25-131 of the 1969 Supplemen
Resource m ssion on the form p
the or of altWhis wei
<
1
a
D
Q0V
I10-71 f
lion of. the well, a 'Well CfSmpletion Report" containing construction de t Is and information required -under
the. General•Statutes must be sent to the owner, the Department of Consumer Protection and the Water
dui the ency. ThisRer t rs vali it all information is filled in and it has been counter -signed by
APPL rS ESS REGISTRATION NO.
'o 4,� �G� C'T�Gz;1
ker or Agenfl
OrPPROVED ❑ REJECTED
MRKS
DATE f! —/.47 yt ^Q !
kRETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION