HomeMy WebLinkAboutChurch St. #33 - 12/31/2021Commonwealth ofMassachusetts
Town of Mansfield
Board of Health
Name of Owner: 7- i,4d ✓ 41ytz L
Lot Address: ,3 3 6 f%l �&I� ~
Town / State / Zip:
Telephone:
Mansfield
Registered wall
Driller: /)
MA LIC #: ;7,7 C>
Business /41^'°L-dir<•'s`�" -
Town / State / Zip:(-'adllai
Email: taZ'7p
TYPE OF WELL: ❑ Domestic Potable (for household use)
omestic Auxiliary (for watering, pools, etc.)
❑ industrial/Commercial Potable (for human consumption, including food processing)
❑ Industrial/Commercial Auxiliary (for manufacturing, etc.)
,.,,
❑ Agricultural (for irrigation of land in the business of agriculture)
0/
FEE: Domestic$75.00 ❑ Industrial/Commercial$75.00 ❑ Agricultural$75.00
Submit application with payment, site plan, pumping test, and quality test to the Mansfield Health Department
located at 6 Park Row, Mansfield, MA 02048.
The site plan must show the well location, property lines, sewer lines, septic systems, animal enclosures, fuel
tanks, other potential contamination sources and features associated with a minimum separation distance,
Domestic Auxiliary (for watering, pools, etc.) and Agricultural (for irrigation of land in the business of
agriculture) Wells do not require a Pumping Test and Quality Test to be submitted with application.
NOTE: Electrical permit required; underground cable trench must be inspected.
DATE:APPLICANTSIGNATURE�` %dss-
Upon installation of well, call Department of Public Works at
508-261-7330 to schedule an inspection.
�jq
0