HomeMy WebLinkAboutChauncy St. #46 - 11/10/1997MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERAM TO DRILL WELL
Name
Address
Location
4
Installer
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Address`
TYPE OF WELL:
_Domestic Potable (for household use)
_Domestic Auxiliary (for watering, pools, etc.)
—Industrial/Commercial Potable (for human consumption, including food processing)
_N6ndustrial/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 Agricultural
Date: 02� 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 t�� _ /, ,%5
_Domestic Potable (for househc.':i use) - —_
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
IndustriaVCommercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
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Date:?% i ! Approved by:
For'tfie Board of Health
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NOTE: Electrical permit required; underground cable trench must be inspected.