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Commonwealth of Massachusetts
�.� Town of Mansfield
Town Mansfield 8 Park Row
Tof M
- _ s f Mansfield, MA 02048
Board of Health
Application for Permit to Drill Well
NAME OF OWNER: �Q �� o REGISTERED ,
� rJun"'Ji WELL DRILLER: iAd J WAWeL wJ.nL�)
ADDRESS OF OWNER: j 1 S 4 22 0we L A MA LIC #: —7 $,
��D4t� BUSINESS
TOWN/STATE/ZIP: Q1AN 51FCL� �j1A ADDRESS: Pa,l � 10IL v nl S
TELEPHONE No: S06 "a`�
i3 1356 31 A R1
5 �s,,,1"e,�T
TYPE OF WELL: Domestic Potable (for household use)
[y� Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing )
El Industrial/Commercial Auxiliary (for manufacturing, etc.)
❑ Agricultural (for irrigation of land in the business of agriculture)
FEE: III Domestic $75.00 ❑ Industrial/Commercial $75.00 ❑ Agricultural $75.00
DATE: 117 APPLICANT SIGNATURE{
Permit to Drill Well
The above application has been approved and permission is granted to drill a well for the following use
0 Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing )
E] Industrial/Commercial Auxiliary (for manufacturing, etc.)
El Agricultural (for irrigation of land in the business of agriculture)
1 \I
DATE: �1�"1� �'� APPROVED
�� � or the Board of Health
NOTE: Electrical permit required; underground cable trench must be inspected.
Upon installation of well, call Department of Public Works at
508-261-7330 to be added to well list,
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