HomeMy WebLinkAboutJennifer Drive #7 - 12/31/2021Name of Owner:
Lot Address:
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Commonwealth ofMassachuseas
Town of Mansfield
Town o Mansf geld 6 Park Ro
f Mansfield
Board of Health
perAmah
or.
Registered Well
Driller: E I IC(S
MA LIC #: %�-
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M Business RiC�a1�1Sc1n C✓a (IS Pr„PS
Town / State / Zip: NWS'1('Il, eI4 / / 1 {� QaQ� g Town / State / Zip:
Telephone: 78I'_ .3 p9" 2 (?9
Email:
TYPE OF WELL: ❑ Domestic Potable (for householduse)
Domestic Auxiliary (for watering, pools, etc.)
❑ Industrial/CommercialPotable (for human consumption, includingfood processing)
❑ Industrial/CommercialAuxiliary(for manufacturing, etc.)
❑ Agricultural (for irrigation of land in the business of agriculture)
FEE: IQ 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, f
tanks, other potential contamination sources and features associated with a minimum sepalratio 410
Domestic Auxiliary (for watering, pools, etc.) and Agricultural (for irrigation of land in the bus' ss of���
agriculture) Wells do not require a Pumping Test and Quality Test to be submitted with appl 69)
NOTE: Electrical permit required; underground cable trench must be inspected.
DATE: t, d-4 �a.1 APPLICANTSIGNATURE
Upon installation of well, call Department of Public Works at
508-261-7330 to schedule an inspection.
Bank k:
Town of Mansfield
SCHEDULE OF DEPARTMENTAL PAYMENTS TO TREASURER
Department: — Public Health Department _.:Dept #
5121__
Schedule M ' Permits-
-_..__.__..___._..._
' Date:
09/22/21
Source Account Number CODE
Amount
Well Driller Permit 1051200-445010
$
75.00
_ _ ______�OHPER _
i
I
------------ ---`-------
T
I
� TOTAL: $
To The Officer Making the Payments:
Ma_n_s_fi__el_d, MA____
_09/22121',
The above is a detailed list of moneys collected by me j amounting in the aggregate, to: _
forthe period ending 09/22121
which I have paid to the Town Treasurer whose receipt I hold therefor.
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Employee or Dept Head
ABLE WELL AREA