HomeMy WebLinkAbout1993-8-19 - 151 Ellington Road - Well Drilling ApplicationI CONSUMER PROTECTION
WELL DRILLING BOARD T TE OF CONNECTICUT
CPR-eREV. 11-e2 DEPARTMEN CONSUMER PROTECTION
• �f� 2] -� j WELL DRILLING PERMIT
4; - r 165 CAPITOt AVE.,.HARTFORD, CONNECTICUT 06106
OCCUPATIONAL LICENSHNIV 171VISI0id
/Dent. of Consumer Protection �n , u /)
LOCATION OF WELL
I
WELL
IF DMDUAL
BUILDER
OTHER (Specify)
root
PERMIT NUMBER
158023
N10FOSED
BUSINESS
DOMESTK El ESTABLISHMENT
FARM
j
TEST
WELL
Est. No. of
People being
USE OF
served.
' WELL
PUBLIC
AIR
OPe d
SUPPLY INDUSTRIAL
CONDITIONING
)
a
Irdioote North
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 of bast two roads Well location on lot and to house (if present)
I ,f 7
J
Approximate number of feet from well to
rebored 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
25191 of the 1969 Supplement to the General Statutes 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 information is filled in and it has been counter -signed by the Director of Health or his agent
)9a_0� / ae &-d O 'o- 2dr-93
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD