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r <br /> / • . <br /> DANE COUNTY 1202 Northport Drive <br /> h - •� ENVIRONMENTAL HEALTH DEPARTMENT Madison, Wisconsin 53704 <br /> vrr" Phone 266-4953 <br /> PERMIT APPLICATION FOR PRIVATE DOMESTIC WATER SYSTEMS <br /> The undersigned hereby makes application for a WATER SYSTEM PERMIT for the premises <br /> described herein. The undersigned agrees that all work performed and equipment installed shall <br /> be in accordance with Chapter 27, Dane County Ordinances and with all applicable laws and <br /> regulations of the State of Wisconsin. <br /> (Fill in completely PLEASE PRINT) SAM'S ROTARY DRILLERS, INC. <br /> e „ .1 /e/�Gti ROUTE 1 - <br /> �(/. RANDOLPH, WISCONSIN 53956 <br /> Owner Driller/Pump Installer <br /> Addr ,;(4,4444/1 / A License No. <br /> Address <br /> Phone Date 441/7f Phone 3.2- f/ <br /> Location of water system:— <br /> Township CO ( TV,A 6.4!/-C ; y4; S Y4; <br /> Sec. 42 / ; Subdivision <br /> Directions to locate property .4 07 41 2 ( <br /> DESCRIPTION <br /> 1. Premises 2. Use(describe exactly as 1-family home, <br /> Lot size ft. x ft. motel, etc. <br /> Acreage <br /> 3. On reverse side draw diagram showing: 3) Filter field (f) <br /> 1) Location of well (w) 4) Location near lake or stream <br /> 2) Septic Tank (s) 5) Location to highway or street <br /> 4. Well log to be submitted <br /> 5. Weight and diameter of casing <br /> 6. Type of grout&method of placing <br /> I certify the information in this application is true an• ' rect: <br /> � t <br /> ure of driller/pump installer <br />