HomeMy WebLinkAbout1971-4-5 - 2241 Ellington Road - Well Drilling ApplicationWELL DRILLING BOARD STATE OF CONNECTICUT PERMIT NUMBER
1NDN" T T-69 WELL DRILLING PERMIT 3906
STATE OFFICE BUILDING, HARTFORD, CONNECTICUT 06115
LOCATION DF �EL 17 rmJ �{` [lvf Num6e.] - — DA
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OW IER OF WELI
❑ INDIVIDUAL Mooso`UILDER ❑ OTHER (Specify)
OWNER'S ADDRESS 11
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PROPOSED �BUSINESS TEST Est. No. of IaOMEST ❑ ESTABLISHMENT ❑ FARM ❑ WELL People being
USE OF served.
WELL PUBLIC AIR OTHER
❑ SUPPLY ❑ INDUSTRIAL ❑ CONDITIONING ❑ (Specify)
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads, snowing distance from intersection and front of lot
Location of lot to at least two roads - l Well location on lot and to house (if present)
Indicate North
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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 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 informo-
tion s led in and it has been unter- ned by the Director of Health r s agan .
N. _ . , _ 1`� , _ v _ _ V Del
BY (fn,rn . �llth OFfi Agenf) DATE
APPROVED ❑ REJECTED
REMARKS ----�
RETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD