HomeMy WebLinkAboutSouth Main St. #165 - 2/2/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
NamerelLa.
Address /C f " .�` IW?
Location &r Sm„ GG „« s.
Installer-gue'baa.-,z
Address
TYPE OF WELL:
Domestic Potable (for household use)
I j 'Domestic Auxiliary (for watering, pools, etc.)
IndustriaUCommercial Potable (for human consumption, including food processing)
IndustriaUCommercial Auxiliary (for manufacturing, etc.)
-:::Agricultural (for irrigation of land in the business of agriculture)
Fee: V Domestic $ 10.00 Industrial/Commercial $ 100.00 N/C Agricultural
Date: 111g F 'If r Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and
following use at / os- S 6 (-? It-, r,
is granted to drill a well for the
DD� mestic Potable (for household use)
✓Domestic Auxiliary (for watering, pools, etc.)
_IndustriaUCommercial Potable (for human consumption, including food processing)
_IndustriaUCommercial Auxiliary (for manufacturing, etc.)
_Agricultural (for irrigation of land in the business of agriculture)
Date: 02 - off- �j Approved by: Jo- �-& k d
For the Board of Health
NOTE: Electrical permit required; underground cable trench must be inspected