HomeMy WebLinkAboutKing St. #45 - 5/25/2005MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address:! /��ilG' S �� Telephone
Location:
Registered
Well Driller: �toVu 2_ �DW V—A-y( MA Lic #
Address:
Domestic Potable (for household use)
tX 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/C Agricultural
Date: Applicant Signature:
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at Lt'S � Sh
Domestic Potable (for household use)
7 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)
Date: Zj u�� Approved by:U 'L r h
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- 733 0 to be added to well list.