HomeMy WebLinkAboutMarshall Ave. #14 - 8/16/2000MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name �ISA& r )n J., (Y(/ /nfj'(L,,
Address_ / `/ %%%Cl S{1tC�/// Alle, Telephone „zi�el
Registered Well Driller PO/(ao d &7ri lj llPd S RWD Number
Address %) /) r 4A P ✓- ln
TYPE OF WELL: ✓Domestic Auxiliary (for landscape watering) Fee: Z$ 10.00
I have read and understand the conditions listed in the permit below and agree to the
conditions.
Date: 4// Af4 Applicant Signature: �C��r� o�) � �G�I,C4
PERMIT TO DRILL A WELL
The above application has been approved and permission is granted to drill a well
at: I 4� I_ �A���'�a f� c �� Aro�
SUBJECT TO THE FOLLOWING CONDITIONS:
1. The resident or owner of the property agrees to use the well for irrigation
purposes only.
2. The resident or owner of the property agrees to allow Textron, Inc. (or their
agent) to sample the well prior to use and on a future periodic basis.
3. The resident or owner of the property will incur no cost for this sampling.
4. The resident or owner of the property must provide to the Health
Department with information regarding construction of the well in the form
of a Department of Environmental Management/Office of Water Resources
Well Completion Report.
5. The resident or owner of the property agrees to notify the Board of Health
as soon as the well is in operation.
Date 2000 Approved by:
For the Board of Health
Follow-up notes for after the well is drilled:
1. Electrical permit required; underground cable trench must be inspected
2. Upon installation of well, call Department of Public Works office at 261-7331 to be
added to well list.
3. Display "Well Water" sign.