HomeMy WebLinkAbout2016-8-16 - 124 Brookfield Street - Well Drilling Permit (2)THE
STEPHEN B. CHURCH
COMPANYFOUNDED 1886
WILLIAM S. DUNCAN, III
JAMES B. DUNCAN, P.E.
49 GREAT HILL ROAD - OXFORD, CT 06478 - PHONE (203) 888-2132 - FAX (203) 888-1863
August 16, 2016
To: Heather Otis
Town of South Windsor
South Windsor Health Department
1540 Sullivan Ave.
South Windsor, Conn 06074
From: Pete Duncan
Stephen B Church Company
Box 67
Seymour, Conn.
Tel: 203 888 2132
Fax 203 888 1863
E-mail Stephenbchn.ao1.coin
Reference: Well Permit
Dear Ms. Otis,
Attached is well permit No 215430 to repair an existing irrigation well at the
Willow Brook Golf Course. Also enclosed is a check for $1.00 made out to the Town of
South Windsor for the well permit.
Please sign the permit and return our copy to us. Thank you for your assistance.
Very truly,
William Duncan
cc: David Fresk
Willow Brook Golf Course
RECEIVED
AUG 2 3 2016
SOUTH WINDSOR
HEALTH DEPT.
WELL AND PUMP SPECIALISTS
CPR-8 Rev 7/95 I PERMIT NUMBER
STATE OF.CONNECTICUT 215430
'at""
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE & PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue, Hartford, Connecticut 06106
LOCATION
�[OFIWELL (Town) (street) (Lot Number) DATE
C41 1 l . 61 t SL CF !l t. (,Ore.
OWNER OF WELL
INDIVIDUAL nJBUILDER OTHER (Specify)
OWNER'S ADDRESS ��II
_ I .1.2r, i s
Est, No. of
PROPOSED DOMESTIC ❑ BUSINESS FARM ❑ TEST People being
USE OF ESTABLISHMENT WELL served.
WELL ;-.�.
PUBLIC El
AIR 0;fHSUPP Y INDUSTRIAL CONDITIONING (Spec ffyy) / ' 4 f' Nc
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 Well location on to and to house (if resent)
I7
Indicate North # 1
5 V
ri
f I
f
Approximate number of feet from well to
nearest source of possible contamination:
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 Department of Consumer Protection and the Water
Resources Commission on 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 Director of Health or his mrit,
APPLICANT (Stnatune) r APPLICANT'S ADDRESS REGISTRATION NO
1
BY Town Mea►fh O r or ent) DATE
1:1APPROVED ❑ REJECTED /` ` Odom /,A � E- t + s 7�' k
DIRECTOR OF HEALTH
.rt- T., ____iniissi: ro5_nusei-0uui _ VG#713410/01 W-881408
CPR-8 Rev. 7195 _.
STAY E OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
READ. ESTATE & PROFESSIONAL, TRADES DIVISION
WELL DRILLING PERMIT
I65 Capi tot Avenue, Hartford, Comes tieu t 06106
•PERM171 NUMBER
'5 4 -3
LOCATION OrFfrWLLL ](Town) (Street) (Lot Number) �. DATE r
seF'- rt API Sdv- 179 f l� c�riJ .,�I'r z, �r�:C�-? 18/1(I'4 %0
OWNER OF WELL "'
INDIVIDUAL GUILDER OTHER (Specify)
OWNER'S ADDRESS �' J
a � lr' �p[7r/H C.
c�• S !? �I w��d/ ter i , t/—j S �•��:�
Est No. of
PROPOSED ❑ DOMESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL � jq r(n qp served.
WELL G: Afrtiti`1�✓_q
❑PUBLIC INDUSTRIAL ❑ AIR ` OTHER l iti•�y ayy�s� Z
SUPPLY _ CONDITIONING (Specify) if.
SKETCH OF WELL LOCATION
Lac -ate 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)
l�
a P .N S
1
Indicate North
S
2
ae
l
IQI-
1
)rotcpu:ItcjoJ
r •
tit � p
��y1J n
b g e S t': V
ZV el okc,,J 0-e Q
(
t � 14v1
7
� s
r
1 3froH
r�+1
Approximate number of feet from well to
nearest source of possible contamination:
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 Department of Consumer Protection and the Water
Resources Commission on 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 Director of Health or his agent. . nvo-
APPLICANT (Sigrraiure) APPLICANT'S ADDRESS REGISTRATION NO.
J LL r 'I ? gstf yj (I 6.40a Ox.:.�l a,, ., A/q - u).-9
BY r Town Health Officer or Aaent) DATE
® APPROVED ® REJECTED
REMARKS
SQ7 5717.V,?-,0 194'A a :A COPY /--I r
T-A4r-A 0 -ri -S c"' 4cl 8/2 6116