HomeMy WebLinkAbout2009-1-5 - 24 Judge Lane - Well Drilling PermitPERMIT NUMBER
CPR-8 Rev.7/95 2 4 5 9 5 5STATEOFCONNECTICUT
DEPARTMENT OF CONSUMER pROTECTION
REAL ESTATE sz pROEEssIONAL TRADES DIVISION
WELL DRILLING PERMIT
165 Capitol Avenue.Hartford,Connecticut 06 1 06
—
DATE
//é)QLOCATIONOFWELL(Town)(Street)(LotNumber)
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OWNER OF WELL
INDIVIDUAL
i E BUILDER OTHER(Speclfy)Ff.)Haw/1Q r.
OWNER'S
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ADDRESS
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PROPOSED D DOMEST'C D BUSINEss D FARM D TEsT Pizglggéiogg
USE OF ESTABLISHMENT WELL served.
WELL PUBLIC INDusTRIAL AIR OTHER
SUPPLY CONDITIONING .(Specify)
SKETCH OF WELL LOCATION
nearest source of posSIble contamination 2 K
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The underSIgned Is aware that upon complellon of the well a Well Completion Report containing construction detal|s and Information reqUIred under
Section 25 131 of the 1969 Supplement to the General Statutes must be sent to the owner the Depanment of Consumer Protection and the Water
the
Resources
Director
CommISSIon
of Health or
on
his
the
agent
form prOVIded by the a IA s p é Is t o valld until al|Information Is flled In and It hasbeen I3:(3
c'gu‘nters r.”Signed
/Aby
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APPLICAN SADDRESS i \ONIM 6’Cwg?REGISTRATION0 l §Y—~NO.x)I
APPROVED D REJECTED ///@
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V\I BY Ith’Off/C or en!)DATE —
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DIRECTOR OF HEALTH
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