HomeMy WebLinkAbout1970-11-2 - 173 Miller Road - Well Drilling PermitSKETCH OF WELL LOCATION
Locate well with respect Io of Ieasf I'wo roads,showing distance from infersedion and from of Io?
Location of Iot to at Ieasf two roads Well location on Iot and to house (if present)
Approximate number of feet from well to
nearest source of possible contamination:
The undersigned is aware that upon completion of the well,a ”Well Completion Report"containing construction details and information required under Section 6 of
Public Act 659 must be sent to the owner,the Board and the Water Resources Commission on the form provided by the Board.This permit is not valid until all informa-
tion is filled in and it has been counter-signed by the Director of Health or his agent.«'5
A),9.“
T (Signatoreg J?VL
xyzo/y
a???
RETURN THES COPY TO CONNECTICUT WELL DRILLING BOARD
f 1:1;;
f
.I "-
WEll DRIllING BOARD STATE OF CONNECTICUT PERMIT NUMBER
WDB-4 11-69 WEll DRIllING PERMIT
STATE OFFICE BUILDING,HARTFORD,CONNECTICUT 061 15
/‘A/wx,g ~'Y If}C IIA,”r‘
LOCATION OF WELL (Town)K II A [(Sfreet)(Lo?Number)
.//‘/3:/"//7 «’I
DATE
Ox—vJg—Jgl‘IE/II I j a!“15.x,L ;g ‘
OWNER OF WELL I
INDIVIDUAL BUILDER
OWNER'S ADDRESS I
D OTHER (Specify)
I L“!LL f I I”'w 5v z?x '‘‘f‘'.'>.
Est.No.ofPROPOSEDDDOMESTICBUSINESSDFARMTEST
WELL People being
USE OF ESTABLISHMENT served.
WELL PUBLIC D INDUSTRIAL AIR OTHER
SUPPLY INDUSTRIAL CONDITIONING (Specify)