HomeMy WebLinkAboutDeer Path Lane #51 - 7/23/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name %cu % 4aeora2
Address :5/ 1)eer Pad! LN Telephone o�6/'
Registered Well Driller 10rl `ll `141, el f- Number e1114
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TYPE OF WELL:
mestic Potable (for human consumption)
mestic Auxiliary (for landscape watering, pools, etc.)
_Industrial/Commercial Potable (for human consumption, including food processing)
—Industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricu tural (for irrigation of land in the business of agriculture)
Fee: Domestic $ 10.00 Industrial/Commercial $ 100.00 N/C Agricultural
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Date: 'M2 Applicant Signature: /�
PERMIT TO DRILL A WELL
The above application has
following use at
is granted to drill a well for the
Domestic Potable (for human consumption)
Domestic Auxiliary (for landscape watering, pools, etc.)
_industrial/Commercial Potable (for human consumption, including food processing)
—Industrial/Commercial Auxiliary (for manufacturing, etc.)
__Agricultural (for irrigation irrigation of land in the business of agriculture)
Date: (� Approved by: .&
For the Board of Healtfi
Follow-up notes for after the well is drilled:
1. Electrical permit required, underground cable trench must be inspected
2. Upon installation of well, call Department of Public Works office at 261-7331 to be
added to well list
3. Display "Well Water" sign.