HomeMy WebLinkAboutCanoe River Dr. #10 - 8/24/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: Lt2 rt n a L/ e r Telephone ,� V 3 3 / 73
Location:
Registered (�
Well Driller: A v 2 i yr v L /1 n !7 MA Lic #
Address:
TYPE OF WELL:
_ Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
IndustriallCommercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
Fee: Domestic $10.00 _Industrial/Commercial $100.00 NA- A ' Itural
Date: Applicant Signature:' R < Cl
The above application
following use at 14,
PERMIT TO DRILL WELL
and permission is granted to drill a well for the
_ Domestic Potable (for household use)
_ Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
—A 'cultural (for irrigat' n of land in the bu mein of agriculture)
Date: ` 2 `Approved by:
Por'-4he Board of Health
NOTE: Electrical permit required, underground cable trench must be inspected
Upon Installation of well, call Department of Public Works office at
26I-7330 to be added to well list:
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LL
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MANS)IaQ, MA 02048 DECELLE W.
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GROUP S DECELLE, JR H
Nm 9188
PROFESSIONAL ENGINEERS PROFNSSIONAL SURVEYOR A Sol
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rex (VOI) 784 6801