HomeMy WebLinkAboutChauncy St. #296 - 10/19/2015MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: '�5'3 Q1vM Yrm � (\S 1 eje ��,V) Telephone ctrl% n"6 7
Location:
Registered ��q
Well Driller: ��Q r ����-t�\ \t n� MA Lic # —A %
Address:
TYPE OF WELL:
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.)
_ Agricultural (for irrigation of land in the business of agriculture)
Fee: �—' Domestic $75.00 - Industrial/Commercial $75.00 _ Agricultural $75.00
Date: \6\Uk\� Applicant Signatures
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at Z',�
omes ' Potable (for household use) (� VI,e°�C_,.----
om tic Auxiliary (for watering, pools, etc.)
In trial/Commercial Potable (for human consumption, including food processing)
In trial/Commercial Auxiliary (for manufacturing, etc.)
gri Itural (for irrigation of land in the busin�e�ss of agriculture)
Date s{ 'i L C 5 Approved by: ti(T i
A the Board of Health
NOTE. Electrical permit required, underground cable trench must be inspected.
Upon Installation of well, call Department of Public Works office at
261-7330 to be added to well list.