HomeMy WebLinkAboutFruit St. #35 - 6/9/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address S f- rt u i i S %/ Telephone 29 - Z fl-f—
Registered Well Driller 24ts�/to &2ce) S�e�i r��`r6C S Number
Address '; LA4),SC/C c 0
TYPE OF WELL:
mestic Potable (for human consumption)
Domestic 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: 1, Domestic $ 10.00 —Industrial/Co ercial $ 100.00 N/C Agricultural
X
X Date: (d - q- % Applicant Signa
PERMIT TO DRILL A WELL
The above application has been approved and permi Sion is granted to drill a well for the
following use at 3 J ra&e6.d+ S
Djj��mestic Potable (for human consumption)
t/Domestic Auxiliary (for landscape watering, pools, etc.)
_Industrial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
_Agricultural (forirrigationof land in the business of agriculture)
Date: �-�6 Approvedby: Jeeez.0-4'k "J"
For the Board of Health
Follow-up notes for after the well is drilleti.
1. 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
added to well list
3. Display "Well Water" sign.