HomeMy WebLinkAboutCentral St. #147 - 7/9/2001MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
i /
Name G'r12v /g }dI''4
Address-zzz & /tvC S4 hone Tele
_ P /-50Y- 339- �V&
Registered Well Driller �i /% RWD Number ' 3 8
Address
TYPE OF WELL: 4l,- 9 4 Ly
_Domestic Potable (for human consumption)
omestic 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/Commer2%eo
0.00 Agricultural
Date: %�S�h t 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 ICJ? C6!k e t-
_Domestic Potable (for human consumption)
omestic Auxiliary (tor landscape watering, pools, etc.)
—Industrial/Commercial Potable (for human consumption, including food processing)
—Industrial/Commercial Auxiliary (for manutkni i g, e .
_Agricultural ( for irrigation of land in the busine s of gric Ituurre)
Dale: %- �I-� I Approved by: /
For he II rd of lie
aith
Follow-up notes for after the well is drilled:
V),
I. 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
dd d
a e to well list
3. Displav "fVell Water" sign.