HomeMy WebLinkAbout Emerson Circle #12 - 12/15/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name���
Address /can
Location
Installer L7C)rU ,�— /</)o/') xz
TYPE OF WELL:
-Vpomestic Potable (for household use)
_Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
IndustrialCommercial Auxiliary (for manufacturing, etc.)
:::Agricultural (for irrigation of land in the business of agriculture)
Fee: / Domestic $ 10.00 Industrial/Commercial 7$ 100.00 N/C Agricultural
Date: Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and permissiop is granted to drill a well for the
following use at /a � m e /L So vt C i /L
_Domestic Potable (for household use)
✓Son tic Auxiliary (for watering, pools, etc.)
_IndustriaUCommercial Potable (for human consumption, including food processing)
_IndustriaUCommercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Date: (�C C . /S f /Cj �j Approved by: /�/_
For the Board of Health
NOTE. Electrical permit required; underground cable trench must he inspecteJ