HomeMy WebLinkAbout2009-5-27 - 110 Brookfield Street - Well Drilling ApplicationCP 8 Rev -1195
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE & PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue, Hartford, Connecticut 06106
LOCATION OF WELL (Town) (Street) (Lof Number)
South Windsor 110 Brookfield St
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ElINDIVIDUAL ❑ BUILDER OTHER (Specify) 91 0 -9,99 6
OWNER'S ADDRESS
PROPOSED
USE OF
WELL
PERMIT NUMBER
245915
5/27109
Dave 1itchell 1 1 0 '?rookf ield St South Nlindsor
Est. No. of
DOMESTIC BUSINESS FARM TEST People being
ESTABLISHMENT WELL served
❑PUBLIC ❑ INDUSTRIAL ❑ AIR ' " OTHER 4
SUPPLY CONDITIONING (Spec )
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 present)
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Indicate North
X
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n well
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Approximate number Ot reel from well to ,
nearest source of possible contamination: 90
The undersigned is avMre-lhat ypm.Fcompletion of the well, a "Welt Completion Report" containing construction details and information required under
Section 25-131 of lwkq 86pplement to the General Statutes must be sent to the owner, the Department of Consumer Protection and the Water
Resources Co fission an the form provided by the agency. This permit is not valid until all information is filled in and it has been counter -signed by
the DirectQ"5HaaIIIL, t3iisradeni-
APPLtC (Sfgnaf
APPLICANT'S ADDRES
REGISTRATION NO
P oel Staves
40
Will-ington
Af
42
BY (T n e h O cer
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DATE
APPROVED REJECTED
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DIRECTOR OF HEALTH