HomeMy WebLinkAboutHeather Lane #15 - 12/31/20214(C)�L01--� Q®
Commonwealth ofNlassachusetts
loivn of Alfav,Sf eld
Board of Health
Town of Mansfield
6 Park Row
Application for Permit to Drill Well &. � 0 <'Dzl l ��
Name of Owner: - /'' Registered Well
V1 C1S Aehl Driller: R)( � Wells �
Lot Address: 15 MA LIC #: QS tl qo
M At I �'j� n Business
Town / State JZip:/� GIh ?1 I(Ji' Il't 0202' Town/State/tip:
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Telephone: 719 -JZli$ Q�Ka Email: e- c V; r A01-. COtM
TYPE OF WELL: t%$en�/ � hC�ii..fE1:i� `rvi�oc, Loam
f�Domestic Potable (for household use)
❑ Domestic Auxiliary (for watering, pools, etc.)
❑ Industrial/Commercial Potable (for human consumption, includingfood processing)
❑ Industrial/CommercialAuxiliary (for manufacturing, etc.)
❑ Agricultural (for irrigation of land in the business of agriculture)
FEE: if 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: �1 APPLICANTSIG NATURE
Upon installation of well, call Department of Public Works at
508-261-7330 to schedule an inspection.
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HEATHER LANE
120.00'
LOT 18
30,000 S.F.
EXISTING
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EXISTING
LEACH FIELD
EXISTING
LEACH FIELD
100' FROM SEPTIC
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ROANLD J. & VIRGINIA �I
BOUCHER /
/ oI PROPOSED
WELL
10' SETBACK
120.00'
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15 HEATHER LANE
OWNER &APPLICANT
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W W BRIAN CISTERNELLI
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MANSFIELD , MA. 02048
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ASSESSORS MAP 37 PARCEL 129
y E/V N9 PROPOSED
POTABLE WELL LOCATION
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N JAMES F. SLOAN N 0.15 HEATHER LANE
IN
KELLY & JAMES BOURAS
M AN15FI EI-FD, M A
JUNE 4 , 2021
SCALE 1 " = 40'
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CRAIG E. CYGAWNOSKI DATE
ENGINEERING CO. INC.
P.O. BOX 32 MANSFIELD, MA. 02048
3) 339-3731 RIMENGINEERING®VERIZON.NET