HomeMy WebLinkAboutBaybrook Farm #30 - 8/5/2002MANSFIELD BOARD OF HEALTH
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APPLICATION FOR PERMIT TO DRILL WELL
Name 05 M /1/
U
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Address: J? O 124 Y612a o r 7'�i92 M r,
Location: H19 /YS F/ c L R 4-
Registered
Well Driller: h- u L l S
Address: - 7 o vr2 G ,!�f? 4ZJ . 54,,�t T�2S
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: ✓omestic $10.00 _ Industrial/Commercial $100.00 N/C Agricultural
Date: S 6_2:� Applicant Signature: B
PERMIT TO DRILL WELL
The above application has
following use at _? O
is granted to drill a well for the
_ Domestic Potable (for household use)
v—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)
y
Date: 5 p Approved by:—4u--tl I C
For 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;