HomeMy WebLinkAboutFarm Pond Path #27 - 5/19/2003MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: d` i �e >> I /}7�'% Telephone
Location: � ^^ G
33r3L�'
Registered
Well Driller:MA Lic #
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 $10.00 _ Industrial/Commercial $100.00 N_//CC Agricultural
Date: ,S� / ` 3 Applicant Signature: C r--�
The above applii
following use at
PERMIT TO DRILL WELL
is granted to drill a well for the
Domestic Potable (for household use)
omestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (for manufacturi , etc.)
_ Agricultural (for irrigation of land in the b e f riculture)
Date: ��. 72 Approved by:
Fo 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.