HomeMy WebLinkAboutWagonwheel Way #15 - 11/18//2002MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
NamegSve_,_4
Address:
Location: . C
Registered
Well Driller: l
Address:
TYPE OF WELL:
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: /\� R / o Z Applicant Signature: �
PERMIT TO DRILL WELL
FET�heabove application has been approved and permission is granted to drill a well for the
use at /5 (ja c rn > IA 6n / /.
_ Domestic Potable (for household use) v
✓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)
Date: Approved b �
For the Board of Hea. th
NOTE: Electrical permit required; underground cable trench must be inspected.
Upon Installation of well, call Department of Public Works office at
26I-7330 to be added to well list
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