HomeMy WebLinkAboutUnion St. #60 - 5/2/2003MANSFJ ELD BOARD OF HEALTH � to iii n
<a
APPLICATION FOR ]PERNuT TO DRILL WELL
Name !� fc (fi rf c n -�> c
Address:
Location: N\ r'� N4 d PlryA 6 Z,G tf k
Registered
Well Driller: J �yi One,
Address:
TYPE OF WELL:
_ Domestic Potable (for household use)
/Domestic Auxiliary (for watering, pools, ow.)
lndustriaYCommereial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
Fee: -k::fDomes6e$10.00 �lndustrial/Commercial$100.00 N/CAgricultural
Date:
Applicant Signature: i "�
The above application has been approved and permission is granted to drill a well for the
following use at ty U'7- 'S t , 'YW) r (d l
_ Domestic Potable (for household use)
X Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food ptooessing)
Industrial/CommercitdAuxiliary (for manufacturing, etc,)
Agricultural (far irrigation of land in the business of agriculture)
Date: J �qb 3 Approved by
Por the Board of Healt
NOTE: Electrical permit requbed, underground cable trench must be inspected
Upon Installation of we14 call Department of Pablic Works office at
261-7330 to be added to well list.
lifo
n 7
V