HomeMy WebLinkAbout1972-8-2 - 2 Christine Lane - Well Drilling ApplicationWELL DRILLING BOARD
WDB-4 11-69
INDIVIDUAL ❑ BUILDER
OWNER'S ADDRESS
PROPOSED DOMESTIC
USE OF
STATE OF CONNECTICUT
WELL DRILLING PERMIT
STATE OFFICE BUILDING, HARTFORD, CONNECTICUT 06115
❑ OTHER (Specify)
PERMIT NUMBER
10848
.2- 7 /_
DATE -07
Est. No. of
People being
served.
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL El CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with rasped to at least two roads, showing distance from intersection and front of lot
Location of lot to at least two roads Well location on lot and to house (if present)
0
Indicate North
o❑
❑BUSINESS TEST
ESTABLISHMENT ❑ FARM ❑ WELL
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is aware ]hot 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 SlaNtes must be sent to the owner, the Board and the Water Resources Commission on the form provided by the Board. This
permit ' o! valid until all informati is filled i and it has been taunter -sign b h Director of H Ith or his agent.
AppL1 gnafura A iJT'$ AD 5 REOSS TION NO.
BY (Town eclth Officer or Agent f DATE
2-APPROVED ❑ REJECTED
REMARKS /_ _,1
DIRECTOR OF HEALTH