HomeMy WebLinkAboutNorfolk St. #45 - 5/5/2017Commonwealth of Massachusetts Town of Mansfield
Town o Mans 6 Park Row
f J Mansfield, MA 02046
Board of Health
Application for Permit to Drill Well
NAME OF OWNER:UqCo,yP-
ADDRESS OF OWNER:[/ �Y✓/� sTYtC7
TOWN I STATE I ZIP:ed
TELEPHONE No: c.,n Z?4/ _ iii z
REGISTERED
WELL DRILLER:
MA LIC #: qlq
BUSINESS
ADDRESS:
Pr9O. PX 5-ql )Pin K `LC Al lC�
TYPE OF WELL: El Domestic Potable (for household use)
❑ Domestic Auxiliary (for watering, pools, etc.)
I I Industrial/Commercial Potable (for human consumption, including food processing )
❑ IrWy1ustrial/Commercial Auxiliary (for manufacturing, etc.)
[4/Agricultural (for irrigation of land in the business of agriculture)
FEE: G Domestic $75.00 ❑ Industrial/Commercial $75.00 L3"Agricultural $75.00
DATE:/1 APPLICANT SIGNATURE
Permit to Drill Well
The above application has been approved and permission is granted to drill a well for the following use
El Domestic Potable (for household use)
XDomestic Auxiliary (for watering, pools, etc.) �cc \cw D r c . co -c" b�
❑ Industrial/Commercial Potable (for human consumption, includin�food processing )
❑ Industrial/Commercial Auxiliary (for manufacturing, etc.)
❑ Agricultural (for irrigation of land in the business of agriculture)
DATE: APPROVED B
the Board of Health
NOTE., Electrical permit required; underground cable trench must be inspected.
Upon installation of well, call Department of Public Works at
508-261-7330 to be added to well list.