HomeMy WebLinkAboutFarm Pond Path #19 - 8/1/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
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Name CAV ul A1_4 r
Address: 1 Et
FOL1- 'Y'1 N a1 PUS, Telephone R)e J 6P101/�s
Location: �F}-V-�, C-
Registered f ")�
Well Driller: Elt <i/ _Wc7 ir'K � 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: G/ D! omtestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: Applicant Signature: ! 46 zt\C� _
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at 16 -� )Fgr� XQj
DQluestic Potable (for household use)
estic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human consumption, including food processing)
_ Industrial/Commercial Auxiliary (form etc.)
Agricultural (for irrigation of land in t e business culture)
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Date: (} Approved by:
r 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