HomeMy WebLinkAbout Copeland Dr. #195 - 8 /25/2008MANSFIELD BOARD OF HEALTH
Name
Address:
Location:
APPLICATION FOR PERMIT TO DRILL WELL
Telephone 337 (.1'6Lr'7
C' off, 3iS' 111SUQ
Registered
Well Driller: eefaGt j`r MA Lic #
Address:
L1
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: A Domestic $10.00 Industrial/Commercial $100.00 N/C Agricultural
Date: Applicant Signature:
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at
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)
Date: Approved by:
For 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.