HomeMy WebLinkAboutWildflower Ln. #14 - 5/10/2017Commonwealth of Massachusetts
Town of Mansfield
Town of Mansfield 6 Park Row
Mansfield, MA 02048
Board of Health
Application for Permit to Drill Well
NAME OF OWNER:�C�
ADDRESS OF OWNER: Iq % 1 ��,/e� ✓ J
TOWN / STATE / ZIP: fi-)/Jn511' ,IAMK
TELEPHONE No: �� 2 c,'�o O
REGISTERED �
WELL DRILLER:
MA LIC #:
BUSINESS C:b 60'b 1 *
ADDRESS:
TYPE OF WELL: 0 Domestic Potable (for household use)
'' Domestic Auxiliary (for watering, pools, etc.)
Industrial/Commercial Potable (for human consumption, including food processing )
0 Industrial/Commercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
FEE: ;; Domestic $75.00 O Industrial/Commercial $75.00 19 Agricultural $75.00
DATE: �G? "-) , I APPLICANT SIGNATURE
i
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 )
Industrial/Commercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the business of agriculture)
DATE: APPROVED Bli
or the Board of Health
NOTE., Electrical permit required; underground cable trench must be inspected.
Upon installation of well, call Department of Public Wffjsg ( mAwssELD
508-261-7330 to be added to well list. PAD
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