HomeMy WebLinkAboutSawmill Ct. #11 - 4/6/2004MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name �L5 S. 1 Liccio
Address: _ :H _1 w �- &11S at Telephone (�-a � -I 3,5 - S-q,) L
Location:
Registered n
Well Driller: 3(A_SQ/1 ULJ� VJri,� �, MA Lie# /SZ
Address: P.O. (SAX S0 �oo.rScal OZ89�
TYPE OF WELL:
_ Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
Industtial/Commercial Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigation of land in the business of agriculture)
Fee: ✓ Domestic $10.00 _ Industrial/Commer ial $ 00 00 N/C A 'cultural
Date: Z? j 0 Applicant Signature:
PERMIT TO DRILL WELL
FF
application has been approv d a! d,permission is granted to drill a well for the
se at -�stic Potable (for household use)
stic Auxiliary (for watering, pools, etc.)
rial/Commercial Potable (for human consumption, including food processing)
rial/Commercial Auxiliary (for manufacturing, etc.)
ltural (for irrigation of land in the busine s Qf agriculture)
�> cj 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