HomeMy WebLinkAboutWinslow Way #20 - 6/4/2004MANSFIELD BOARD OF HEALTH
APPLICATION FOR PERMIT TO DRILL WELL
Name
Address: Z1 Telephone �iGr' (/— f •//)
Location:
Registered
Well Driller: MA Lic #
Address:
TYPE OF WELL:
_ Domestic Potable (for household use)
_,2!L 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: A Domestic $10.00
Date:
_ Industrial/Commercial $100.00 N/C Agricultural
Applicant Signature:
PERMIT TO DRILL WELL
The above application has been approved and permission is granted to drill a well for the
following use at c:2 (
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: ( L`'4 Approved by:(_SJk %'
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.