HomeMy WebLinkAboutSchool St. #170 - 5/6/1998MANSFIELD BOARD OF HEAL'
APPLICATION FOR PERMIT TO DRILL
Name
MY
LL m OF -Is'-;
Address1 :20 y` } r=c C _- Telephone *-3-5 ? - �'-9 8
Registered Well Driller /1%1// tJ eci � ®', �,AK Number
Address
TYPE OF WELL:
_Domestic Potable (for human consumption)
�" omestic Auxiliary (for landscape 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)
Fee: ---Domestic $ 10.00(
Date: 4p
Industrial/Commercial $ 100.00
Applicant Signature
PERMIT TO DRILL A WELL
N/C Agricultural
The above application has b en appr ve d permission is granted to drill a well for the
following use at (-1 f � �'
Domestic Potable (for human consumption)
X,,Domestic Auxiliary (for landscape 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 b e - f agriculture)
Date: Vl. C Approved by'
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.