HomeMy WebLinkAboutWinslow Way #15 - 5/16/200101/09/1994 02:20 5082617343 PAGE 01
MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name z aCU,e_4?6tC c Z , /4 /-7r..('42r'.S cri,
Address / ES GC n .> fi L" l C yt ' �T elephone 1,6') 33 " ? 3 ,3
y Jci da i �1'�
Registered Welt Driller c t 11l%(Af/ (, La v,r RWD Number
Address tG5 c u r '' wl� r lam') �{ L, L 3 2,
4
TYPE OF WELL:
_Domestic Potable (for human consumption)
Domestic Auxiliary (for landscape watering, ,pools, etc.)
—Industrial/Commercial Potable (for human consumption, including food processing)
Industrlal/Commercial Auxiliary (for manufacturing, etc,)
-Agricultural (for irrigation of land in the business of agriculture)
Fee: XDomestic $ 10.00 Industrial/Commercial $$ 100.00 N/C Agricultural
Date: / a / Applicant Signature; "\
PERMIT TO DRILL A WELL
The above application has been approved and permission is granted to drill a well for the
following use at
Domestic Potable (for human consumption)
-!:Domestic Auxiliary (for landscape watering, pools, etc.)
Industrial/Commerciai Potable (for human consumption, including food processing)
industrial/Commercial Auxiliary (for manufacturing, etc.)
Agricultural (for irrigation of land in the bus'
ne s ofagriculNre)
Date: ((> ( Approved by: "®
r e Board of Health
Follow-up notes for after the well is drilled:
1. Electrical permit required, underground cable trench mast be inspected
2. Upon installation of well, call Department of Publie Works office at 261-7331 to be
added to well list.. �-
3. Display "Well Water" sign.