HomeMy WebLinkAboutMill St. #294 - 4/14/2006MANSFIELD BOARD OF HEALTH
APPLICATION FOR PEPJYM TO DRILL WELL
Name (
Address: 6�2 Telephone
Location: 112 4 /L5;0�-/ � z d
Registered 6�"
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Well Driller: d &., c d /fS MA Lic #
Address:
TYPE OF WELL: L
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.)
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Fee: '-'Domestic $10.00 Industrial/Commercial 00 N/C
Date:'"?' Applicant Signature:
PERMIT TO DRILL WELL
The above application has
following use at 77 j
approved and permission is granted to drill a well for the
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 oPagriculture)
Date: J ' (-(f Approved by:
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
261-7330 to be added to well list: