HomeMy WebLinkAboutHodges St. #22 - 6/14/2002MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name rRt4N K - li,El-lT
Address:
S
Location: M AVt4-s�(e \ A N V(
Registered
Well Driller:
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 -oflandin-the business of agriculture)
Fee: ✓ Domestic $10.00 _ Industdal/Commercial $100.00 N/C Agricultural
Date: (��/T G� Applicant-Signatur �--
PERMIT TO -DRILL WELL
The above application has
following.use at _ZL
approved and permission is granted to drill a well for the
Domestic Potable (for household use)
/>C Domestic Auxiliary (for watering, pools, etc.)
_ Industrial/Commercial Potable (for human co surn�tion, including food processing)
_ Industrial/Commercial Auxiliary (for man ctunng, etc.)
_ Agricultural (for irrigation of land in the.b in*Wagriculture) -
Dater =` i 6!v�Approved by: V V
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
261-7331 to be added to well list