HomeMy WebLinkAbout1974-8-26 - 1 Christine Lane - Well Drilling ApplicationWELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
wD" 11-69 WELL DRILLIN4,. PERMR 25212
STATE OFFICE BUILDING, HARTFORC, CONNECTICUT 06115
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LOCATION OF WELL [Town] (gtraat) (Lot Number)
DATE
SOUTH WINDSOR -R8*0 lrj
8/26/74
OWNER OF WELL
❑ INDrvIDUAL ❑i BUILDER ❑ OTHER (Specify) CARLO PRESTILIO
OWNER'S ADDRESS
69 ASH ROAD, WAPPING, CONN.
® BUSINESS TEST Est' No. of
PROPOSED DOMESTIC ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
OTHER
WELL PUBLIC AIR ❑ SUPPLY ❑ INDUSTRIAL ❑ CONDinoNING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads, showing distance from intersection and front of lot 4
Location of lot to at least two roads
Well Jocation on lot and to house Gf present)
ndicate North
IQD_ 0.
AT
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Approximate number of feet from well to
nearest source of possible contamination: Sanitary ary Sewers _
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 font provided by the
Board. 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.
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APPLICANT'S ADDRESS
i REGISTRATION N
LAKE ST. , CONN..
1 100
f' 9Y own Heuilh jleer or yant)
•
❑
DATE
APPROVED REJECTED
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Vz- Nn
REMARKS- _
SCAN IN
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD