HomeMy WebLinkAboutRIverside Dr. #9 - 5/4/2011Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Application for Permit to Drill Well
NAME OF OWNER: / p/ V L�n//�tY�l/ REGISTERED C CrC c Vt v /a
WELL DRILLER: /
ADDRESS OF OWNER: �t2��! MA LIC #: q�
TOWN / STATE / ZIP: )07)AvioLE�p i )v- az76q BUSINESS �•A�(, ��i !/O 1r/p
ADDRESS:
TELEPHONE No:
TYPE OF WELL: E] D stic Potable (for household use)
stic Auxiliary (for watering, pools, etc.)
C7 Industrial/Commercial Potable (for human consumption, including food processing )
0 Industrial/Commercial Auxiliary (for manufacturing, etc.)
�//❑ Agricultural (for irrigation of land in the business of agriculture)
L FEE: Domestic $10.00 ❑ Industrial/Commercial $100.0 O N/C Agrici Itu I
DATE: eJ .V// APPLICANT SIGNATURE
Permit to Drill Well
The above application has been approved and permission is granted to drill a well for the following use
stic Potable (for household use)
Domstic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing )
Industrial/Commercial Auxiliary (for manufacturing, etc.)
El Agricultural (for irrigation of land in the business of agriculture
DATE:
V �l
� [!(/ r' APPROVED BY
For the Board of Health
NOTE., Electrical permit required; underground cable trench must be inspected.
Upon installation of well, call Deaprtment of Public Works office at
261-7330 to be added to well list.