HomeMy WebLinkAbout1996-9-16 - 153 Clark Street - Well Drilling ApplicationPERMIT NUMBER
CPR-8 Rev. 7/95 7
e ' 177
STATE OF CONNECTICUT � (��f � 1 0
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DEPARTMENT OF CONSUMER PROTECTI.; v
REAL ESTATE & PROFESSIONAL TRADES DIVIS N +
WELL DRILLING PERMIT OCT 1-1 19961
16 apttol Avenue, Hartrord, cti t 06rr
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LOCATION OF WELL (Town) (Slreety rlaNumbo r1 ua
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"..�......_�_ IDUAt ILDER OTHER (Specify)
OWNER'S ADDRESS
Est. No of
PROPOSED ESTIC BUSINESS FARM TEST People being
USE OF ESTABLISHMENT WELL served
WELL
PUBLIC 1:1SUPPLY D INDUSTRIAL EJ CONDITIONING AIR OTHER
per
SKETCH OF WELL LOCATION
Lorate'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 (ll present)
(a �V
Indicale North R
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
thytVrector of Health or his agent.
zzgatare) APPLICANTS ADD REGISTRATION NO.
o H a/rh OicerorAgeno DATE
r-1 APPROVED ❑ I PEE D I k-
REMARKS
-
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION