HomeMy WebLinkAboutMarshall Ave. #59 - 6/15/2016MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name Pear S{cg%ae•�
Address: S1A 1^�y(5l.all /kJ Telephone
Location:
Registered +O(--� � � �I ��
Well Driller:���t MA Lic # _tom_
Address: 3c� p i•
M_�'l�xila�hrL�lllJi
Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
IndustriaUCommercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
Fee: t/ Domestic $75.00 _ Industrial/Commercial $755.00 _ Agricultural $75.00
Date / Z � '� Applicant Signature: Ile
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at :S�
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)
1 r
Date:, (7C Approved by:
r 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