HomeMy WebLinkAboutHub Folding Box - 5/5/2017Commonwealth of Massachusetts Town of Mansfield
Town o Mans 6 Park Row
f J Mansfield, MA 02046
Board of Health
Application for Permit to Drill Well
NAME OF OWNER:UqCo,yP-
ADDRESS OF OWNER:[/ -5' �Y✓/�i s[YtC7
TOWN f STATE I ZIP:ed
TELEPHONE No: c.,n Z?4/ _ iii z
REGISTERED
WELL DRILLER:
MA LIC #: qlq
Ryo-n Ora -33
BUSINESS
ADDRESS:
Pr9O. PX 5-ql )Pin K `LC Al lC�
TYPE OF WELL: El
Domestic Potable (for household use)
❑ Domestic Auxiliary (for watering, pools, etc.)
I I Industrial/Commercial Potable (for human consumption, including food processing )
❑ IrWy1ustrial/Commercial Auxiliary (for manufacturing, etc.)
[4/Agricultural (for irrigation of land in the business of agriculture)
FEE: G Domestic $75.00 ❑ Industrial/Commercial $75.00 ]4" Agricultural $75.00
DATE:/ 1 APPLICANT SIGNATURE
Permit to Drill Well
i
The above application has been approved and permission is granted to drill
i
a well for the following use
❑ Domestic Potable (for household use)
XDomestic Auxiliary (for watering, pools, etc.) �cc \uv D r c .
co—c" b�
E]Industrial/Commercial Potable (for human consumption, includin�food
processing )
❑ Industrial/Commercial Auxiliary (for manufacturing, etc.)
❑ Agricultural (for irrigation of land in the business of agriculture)
DATE: tS \ -1 APPROVED B
t'the Board of Health
NOTE., Electrical permit required; underground cable trench must be inspected.
Upon installation of well, call Department of Public Works at
508-269-7330 to be added to well list.