HomeMy WebLinkAbout1970-11-23 - 114/116 Buckland Road - Well Drilling PermitWELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMB:R
WDB-4 11-69 WELL DRILLING PERMIT 2632
STATE OFFICE BUILDING, HARTFORD, CONNECTICUT 06115
OWNER OF WELL
® INDIVIDUAL ❑ BUILDER ❑ OTHER (Specify) Wf
OWNER'S ADDRESS
PROPOSED rl BUSINESS
USE OF (/
DOMESTIC Ll ESTABLISHMENT
LIC
AIR
THER
WELL ❑ SUPPLY ❑ INDUSTRIAL El CONDITIONING ❑ (Specify) S
491
In
SKETCH OF WELL LOCATION
Locate well with Feapad to at least two roads, showing distance from intersection and front of lot
tnroon of lot to at least two .ro4_ Well locunan on 101 an&40 house 04MEM*. v......�
3Uc_ /< 16,
Approximate number of feet from well to
nearest source of possible contamination:
R
The undersigned is aware that upon completion of the well, a "Well Completion Report" containing construction details and information required under Section 6 of
Public Act 659 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 informa-
tion is filled in and it has been counter -signed by the Director of Health or his agent.
❑ APPROVED ❑ REJECTED
REMARKS
N
I REGISTRATION NO.
DATE
DIRECTOR OF HEALTH
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