HomeMy WebLinkAboutUnion St. #123 - 5/21/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name b A /� H IH- Cfd d -`t. V
Address _ U n/ / 6 nJ S j Telephone 676 P 33 q- S /g
Registered Well Driller 2/4/ 6)6 OA-r.l
TYPE OF WELL:
_Domestic Potable (for human consumption)
r _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 business of agriculture)
Fee: Domestic $ 10.00 —industrial/Commercial $ 100.00 N/C Agricultural
Date: _&�l8 Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approved and permission is granted to drill a well for the
following use at Q 3 0 L (4AJ S7—
—_
✓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 busi ss of agriculture)
Date: Date: z:i-I i r Approved by. V
o e 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.