HomeMy WebLinkAboutWinslow Way #10 - 5/18/1998MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name k16ARAJ S01111�f
Address /Z? Zt ,V Telephone '1 1—?S 2' 1
Registered Well Driller6LOQC,�_ 2Ais41 L4T& 6,cl/ 5S'YiCjj Number
Address 6_5 Z6t,i 5"L St- 6'?- 3,AV
TYPE OF WELL:
_Domestic Potable (for human consumption)
Domestic Auxiliary (for landscape 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
Dater Applicant Signature:
PERMIT TO DRILL A WELL
The above application has been approv and permission is granted to drill a well for the
following use at kb w J d � tti N
Domestic Potable (for human consumption)
Domestic Auxiliary (for landscape 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 busi s f agriculture)
Date: 6 l Approved by:
F r the d of Health
Follow-up notes for after the well is drilled:
1. Electrical permit required, underground cable trench must be inspected
2. Upon installation of well, call Department of Public Works_ office at 261-7331 to be
added to ivell list �
3. Display "Well Water" sign.p'
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