HomeMy WebLinkAbout2002-2-8 - 1043 Foster Street Extension - Well Drilling ApplicationPERMIT NUMBER
STATE OF CONNECTICUT 2 1 1 1 3 8
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue.Hartford,Connecticut 08 1 06
CPR—a Rev.7/95
RETURN THIS COPY TO DEPARTMENT OF CONSUMER PROTECTION
LOCATION OF WELL (Town)(Slmel)(LatNumber)
S.WINDSOR 1043 FOSTER ST.EXT.
DATE
2 /8 /0 2
'OWNER OF WELL INDIVIDUAL a BUILDER D OTHER (Specify)
OWNER'S ADDRESS
PAGANELLI CONSTRUCTION P .O .BOX 652 I SUFFIELD
PROPOSEDUSE OF“ELL
E DOMESTIC D BUSINESS D FARM a TESTESTABLISHMENTWELL
SUPPLY
PUBLIC D .mousmfL
:I
AIRCONDITIONING D (Speufy)
OTHER
Est No.ofPeoplebeingserved.
4
'SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersedion and front of lot
Iocation of lot to at least two roads Well Iocation on to and to house (if present)
Indicate North
DOA (Cr R tu.Ra
I
O Wwl
GI't"
$2,
(3zq
I
It ’
$62 WWK _
Approximate number ot feet from well to ABANDONMENTnearestsourceofpossiblecontamination:
The undersigned is aware that upon completion of the well,a ‘Well Completion Report"containing construction details and information required under
Section 25-13120f the 1969 Supplement to the General Statutes mustbe sent to the owner,the'Department of Consumer Protection and the Water
Resources Commission on the fonn provided by the agency.This pennit is not valid until all information is filled in and it hasbeen counter-signed by
the Director of Health or his agent.
A PLICANHSigna APPLICANTS ADDRESS
P .O .BOX 406 ,WILLINGTON,CT .
REGISTRATION NOI
4 2
v‘PPROVED REJECTED BY (Town Health Office orAg n!)
QO
DATE2 73 -0 L
REMARKS I