HomeMy WebLinkAbout2012-3-15 - 116 Lisa Drive - Well Drilling Permitwr .w w ...—
‘>Vanguard Direct Rocky Hin,CT -VG #01-7315754 11/07 W-104280
PERMIT NUMBER
CPR-8 Rev‘7/95
STATE OF CONNECTICUT Egwgga
DEPARTMENT OF CONSUMER PROTECTION ”4R 74 2012REALESTATE&PROFESSIONAL TRADES DIVISION
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165 Capitol Avenue,Hartford,Connecticut 06106
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LOCATION OF WELL I (Town)(Street)(LotNumber
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DATE
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OWNER OFWELL V
,INDIVIDUAL BUILDER OTHER (Specify)
OWNER'S ADDRESS AgpAtmm)
PROPOSEDUSE OFWELL
l
DOMESTIC BUSINESS B FARM TESTESTABLISHMENTWELL
(Specimw
get)‘rAAfPUBLICINDUSTRIALAIROTHERSUPPLYCONDITIONING
Est.No.ofPeoplebeingsewed.
SKETCH OF WELL LOCATION
Locate well with respect to at Ieasl two roads,showing distance from intersection and front of Iot
location of Iot to at least two roads Well location on to and to house (if present)
f
/
r’l
L)6w
L/m &/,
Approximate
nearest source
number
of possible
of feet
contamination:
from well to 25 ’+
The undersigned is aware that upon completion of the well,a “Well Completion Report"containing construction details and information 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
the
Resources
Director
Commission
of Health or his
on the
agent
form provided by the a Ac .This per ?.
i Sis not (9/02?valid until
S
all information'is e ml i.d in and it has been counter-signed by
APPLICA 'gnature)
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F Ayn/H a/Lmmj
APPLICANTS ADDRESS §Qjfl
L,q Ma}MN A/5%Ieh em 07‘
REGISTRATION NO.
1.x,,h IVJETEXDV,’B (Town Health Officer or Agent)
.i'
DATE .
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PERMIT NUMBER
CPR-8 Rev.1’95 3 8STATEOFCONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
REAL ESTATE &PROFESSIONAL TRADES DIVISION
WELL DRILLING pERMIT ”4/?74 2072
1 65 Capitol Avenue,Hartford,Connecticut 06 1 06 SOU
-H TH W IND
LOCATION OF WELL ""H (Town).(Sheet)(Lo!Number)3 DATE L EPT
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location of lot to at least two roads Well location on to and to
Indicate North
r
\Approximate number of feet from well to
nearest source of possible contamination:
v,The undersigned is aware that upon completion of the well.a “Well Completion Report"containing cons—tr-uction details and information 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‘perit Is not valid until all infrmation is filled in and it has been counter-Signed bymo
the Director of Health or his agent.U ‘v fé.‘I re.to?i?q x (,Lg‘’vxi
K
OWNER OF WELL "’«BUILDER OTHER (Specify)
OWNER’S ADDRESS £4 4"5%,,a 5 r a»4’}Est.No.of
PROPOSED DOMESTIC BUSINESS .FARM TEST People being
USE OF ESTABLISHMENT WELL served.
WELL 14¥AIR i OTHER
r”?‘E/"L:(
»,*iPUBLICINDUSTRIALEj(SpecifyH-V‘“
K}
SUPPLY CONDITIONING L
SKETCH OF WELL LOCATION
—Locate well with respect to at least two roads,showing distance from intersection and front of lot
APPLIC _IrSignature)ADDRESS ff .
f £7:V iii 7 5‘[Lg/.1 ,4/4,!
g.APPROVED REJECTED
B (own Health Officer orAgent)DATEI
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REMARKS
Ii /
DIRECTOR OF HEALTH