HomeMy WebLinkAboutWillow St. #361 - 7/29/2015MANSFIELD Bc)AAD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name go k ✓V\ Ma, � U ZAC- (A e w-A
Address: 3 (o f W t I( 0 UJ S 7— Telephone L161 -- a IS-- 8d o
Location:
Registered
Well Driller:
Fl "Y
Address: 19,-
TYPE OF WELL:
L"rti m o
Domestic Potable (for household use)
M
MA Lie #
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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 $75.00 Industrial/Commercial $75.00 Agricultural $75.00
r ( Date: IT pp � g XA licant Signature:
� �icY_
PERMIT TO DRILL WELL
The above application has
following use at 'mot ;;1;;
is granted to drill a well for the
estic Potable (for household use)
omestic 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 bpsi9 es's of agriculture)
Date:Approved by:
I ` For 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- 733 0 to be added to well list.