HomeMy WebLinkAboutDean St. #176 - 9/15/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address_/) 7i Pin s i
Installevn S e Z F
Address
TYPE OF WELL:
Domestic Potable (for household use)
:26ornestic 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)
Fee: 'Domestic $ 10.00 —Industrial/Commercial $ 100.00 N/C Agricultural
Date: 11..5` // 9 7 Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and permission is granted to drill a well for the
following use at (p t F /-1,t) S-"'
mestic Potable (for household use)
_Domestic Auxiliaryfor watering,
_Industrial/Commial Potable (for human consumption, including food processing)
_Industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Date: Approved by:% 'f
For the Board of Health
NOTE: Electrical permit required, underground cable trench must be inspected