HomeMy WebLinkAboutFrancis Ave. #45 - 9/12/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name rtiFcvC ✓/ jf� ';[ �
Address: J / 6. f&�3 IJC(. v. &j G� Telephone (50 gQ — J'-2 3 — 6 7 o3
Location: F.zegf P� 1,
Registered
Well Driller: L,r S orr W rzLL 1 YL,�,� � MA Lia # 2
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)
u: Do Fee: mestic $10.00 _ IndustriaUCommercial $100.90? N/C Agricultural
.10
Date: 2/.Z/ Applicant Signature:
PERMIT TO DRILL WELL
The above applicat'*on� been approved and permission is granted to drill a well for the
following
Domestic Potable (for household use)
mestic 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 bu ' ens of agriculture)
Dater(y Approved by:
or 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
26I-7330 to be added to well list