HomeMy WebLinkAbout2016-7-29 - 219 Lawrence Road - Well Drilling PermitPERMIT NUMBERCPR-8 Rev.7/95
2tSTATEOFCONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE 8K PROFESSIONAL TRADES DIVISION
WELL DRILLING PERMIT
I 65 Capitol Avenue.Hartford,Connecticut 06 l 06
DATE,‘'LOCATION OF WELL “f (Town)W (Sheet)-w;(LotNumher)
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OWNER OF WELL
INDIVIDUAL $§E BUILDER D OTHER(Speclfy)
OWNER'S ADDRESS
DIRECTOR OF HEALTH
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PROPOSEDUSE OFWELL
DOMESTIC m BUSINESS FARM TESTwesTAaLIsHMENT£2 WELL
PUBLIC §INDUSTRIAL AIR OTHERSUPPLYIi:CONDITIONING (Specify)
Est.No‘ofPeoplebeingserved.
SKETCH OF WELL LOCATION
Locate well with respect to at least two roads,showing distance from intersection and front of Iot
location of lot to at Ieast two roads Well Iocation on to and to house (if present)
Indicate North
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Approximate number of feet from well to
nearest source of possible contamination:3 _‘0 San I ,l ‘ne
The undersigned is aware that upon completion of the well,a ”Well Completion Report"containing construction details and infonnation required under
Section 25-131 of the 1969 Supplement to the General Statutes must be sent to the owner,the Department of Consumer Protection and the Water
Resources/Commission on the form provided by the agency.This permit is not valid until all information is fllled in and it has been counter-signed by
the Director of Health or his agent.
APPLI A T ignature)A “a VG iv’.r»APPLICANT’S ADDRESSnr‘a nAxA g I';r4j.:REGISTRATION NO.a
7 z APPROVED REJECTED
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BY (Town Health Officer or Agent)
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DATE
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