HomeMy WebLinkAbout1972-2-2 - 105 Ident Road - Well Drilling ApplicationRETURN THIS COPY TO CONNECTICUT WELL DRILLING BOARD
Will :§RIlllNG BOARD STATE OF CONNECTICUT
WDB-4
¢I ,1 1-69 Will DRIllING PERMIT
l FICE EUllDlNG,HARTFORD,CONNECTICUT 061 15
o u Ta I M w So R
~A;'0 E H T zm a _b‘f B
manor:OF wm (row)(Shea?)(Lo!Number)
IEKRV.)6ulL05KS ALmg,
DATE R -.2 ~72
OWNER OF WELL '
INDIVIDUAL E/aLumm D OTHER (Specify)
OWNR'S ADDRESS’>5 'l vKmP/T/m I?o WlwosoA LocXJ‘.a M M—
PROPOSED
USE OF
WEll
E/Domasnc
-BUSINESS
ESTABIISHMENT D FARM ‘V TESTwm
SUPPIY
PUBLIC D mnusmAL D SOIRNDI'HONING D (5PeClfY)
OTHE.R
Est.No.of
People being
served.
SKETCH OF WEll LOCATION
Locate well with respect Io oi leas?two roads,showing distance from intersection and front of lot
Location of Iol Io of Ieasi fwo roads Well Iocalion on lol and lo house (if presenf)
Indicate North
Rev 7 E 5/
3 TA v ri a fl a
g“ER WK!~E
I3o
f 'RM 'o !'/
Approximate number of feet from well to /I
nearest source of possible contamination:73
The undersigned ls aware that upon complehon of the well a “Well Complehon Report"containing construction details and Information requrred under Section 6 of
Public Act 659 must be sent to the owner,the Board and the Water Resources Commission on the form provrded by the Board This permit Is not valid untul all Informa-
tlon Is mled m and it has been counter-I n b the Dlrector of Health or his agent
V
Cm»;”way/fa tesm'v/haul}$o
AmiCANrs ADDRESS
I 3 2 Swifz RD has’)’Lwg "Ia/i 0"“I'h i165
REGISTRATION NO.
2 8'
BY (Town Health OfFcer or Agent)
APPROVE D REJE§TED 2/j?
DATE 7
REMARKS //v .