HomeMy WebLinkAboutFieldstone Dr. #58 - 6/11/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address Telephone St 1
Registered Well Driller k 4 z 6<��_ 5 L4 Number
Address ' K
TYPE OF WELL:
_Domestic 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: ✓ Domestic $ 10.00 —Industrial/Commercial, $ 100.00 N/C Agricultural
Date: Applicant Signature
PERMIT TO DRILL A WELL
The above application has been
,Approved and permissio is granted to drill a well for the
filoollowing use at s kr/ a 3s-/y/-)Z 1
V Domestic 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 busin s of agriculture)
Date: � � 6 � ��J Approved by:
For the Board of Health
Follow-up notes for after the well is drilled:
1. Electrical permit required, underground cable trench must be inspected
2. Upon installation of well, call Department of Public 'Works office at 261-wl to be
added to well list
3. Display "Well Water" sign.