HomeMy WebLinkAboutWagonwheel Way #11 - 6/25/2003aw ri .S-Q
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name 1V 1 a`f-1'G JAf F: (:DVI Q
Address: Wm(o (/l)keel1 lin' l" Telephone Q6(-)-g a
Location: r,
Registered
Well Driller: MA Lic #
TYPE OF VVELL:
Domestic Potable (for household use)
Domestic Auxiliary (for 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: (p �5r ZS 3 Applicant Signature: 1 `)
PERMIT TO DRILL WELL
The above applicatio has been a prow d and ermi' Sion is granted to drill a well for the
following use at _ J _; ,_ �` / ,3 E'� �, O i Z {
,.Domestic Potable (for household use)
Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing)
Industrial/Commercial Auxiliary (for manuf e"ing, etc.)
Agricultural (fo irrigation of land in the tress o griculture)
Date: > Approved by:
T r 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
261-7330 to be added to well list: