HomeMy WebLinkAboutEmerson Circle #2 - 7/1/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Y Name /erry (y �Ps1 f�1PC%/2/
V. Address Telephone g,39--2
Registered Well Driller Number
Address
TYPE OF WELL:
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 of land in the business of agriculture)
Fee: ✓ Domestic $ 10.00 Industrial/Commercial $ 100.00 N/C
Date: l III b 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 Z 64t -eGSA/ C—lAeC CE
_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 of land in the busingnof agriculture)
Date: �L�L Approvedby:
Fot4e Board of Health
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.