HomeMy WebLinkAboutStillbrook Ln. #11 - 3/12/200203/11/2002 MON 11:18 PAA 3V+$ col 144� ♦unry ui un �.......
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MANSFIELD BOARD OF HEALTH
Name
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APPLICATION FOR PERMIT TO DRILL WELL
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WIR 1 2 W f
_ DoatestisPoiable (for household use)+I eno R ` ' P `
X Domestic Auxiliary (for watering, pools, etc.) `' va j
_ Industrial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
_---Agrie ura tion of land in the business of agriculture)
Fee: X Domestic $10.00 Industrial/Commercial $100.00 N/C Agricultural
pplicant Signature:
Registered S (Aj
Well Driller. l
Address:
0 d DVISO C,V-e* 1�'— ( ®Z 2-
TYPE OF WELL:
PERMIT TO.DRILLWELD
The above application has been approved and permission is granted to drill a well for the
follo,xing.useat C,1J
_ Domestic Potable (fur household nse)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commerciai Potable (for human consumption, including food processing)
Industrial/CommeroW Auxiliary (for manufacturing, etc.)
_ Agricultural (for irrigation of.land �in th stnes� of agriculture)
Date: 2 (proved by:
or 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
261-7331 to be added to well list