HomeMy WebLinkAboutMarie Dr. #18 - 4/3/2019Commonwealth of Massachusetts
Town of Mansfield
o Mansfield
s Park Row
Town
f Mansfield, MA 02048
pgf�NSA-
Board ofHealth
Application for Permit to Drill Well
NAME OF OWNER:
ADDRESSOFOWNER:t�`Gf
TOWN / STATE / ZIP: Jh ��; f ,r, G'L
TELEPHONENo:;j 7a�.
REGISTERED ,d�oL.-✓��E
WELL DRILLER: �i.•G �� F���f� G G'
MA LIC #:
BUSINESS —
ADDRESS:
TYPE OF WELL: � , n mestic Potable (for household use)
omestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for humarn consumption, including food processing)
❑ Industrial/Commercial Auxiliary (for manufacturing, etc.)
❑ Agricultural (for irrigation of land in the business of agriculture)
DATE:
FEE: VJ-- Domestic $75.00 ❑ Industrial/Commercial$75.00 ❑ Agricultural$75.00
APPLICANT SIGNATURE
The above application has been approved and permission is granted to drill a well for the following use
❑ 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)
DATE: t ��Zj `� APPROVED B
or 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 schedule an inspection.
w