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IL 1 11) V. <br /> State of Wisconsin t ` l lq lk4 117; id \', it:, 1 ` COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> Department of Natural Resources 'J1!'-' ' `�' I Form 3300-76 Rev.8-97 <br /> ‘1" L-11 , '' I County Well Permit No. Co <br /> 1.1',; MAR 2 1 2013 11 W 000% viol <br /> IN ORLMATION TO BE C OMP LETED BY THE APPLICANT <br /> Property Owner(Print) ele h n <br /> -1-it tip;�; �p Q,Q l�hlhSbFJ G� Site Development Plan(If required by the County) <br /> BIIUGaV Properties Ft l`' VO__ J Building Plan Dr Sanitary Plan > Other <br /> P9�Z3 ❑ Attached ❑ Attached ❑ <br /> Mailing Address(Print) 11 Location � U City U Village ' <br /> ell ocation Town <br /> 4835 Alvin Rd OF_Sun Prairie <br /> City State Zip Code Well Street Address Fire No.(If available) <br /> Sun Prairie WI 53590- LaRue Fields 2776 <br /> Well Type Subdivision Name or Certified Survey Map No. Lot No. Block No. <br /> 12 New ❑ Replacement ❑ Reconstruction CSM 9968 <br /> 1 <br /> Well is a Tax Parcel No.(If available) <br /> ❑ <br /> Drilled ❑Driven Point ❑Jetted ❑Other <br /> 058/0811-323-9560-0 <br /> ,Current number of wells on property: 0 Gov't Lot No. or SE 'A of SW•/ of <br /> i — <br /> 'Number of unsafe,unused or noncomplying wells to be abandoned: 0 Section 32; T.8 N; R.11 Jt❑ E ❑W <br /> Designated Agent's Name(Print) Well Constructor(Print)(If known) License No.(If known) <br /> ELLYN REDEKER SAM'S ROTARY WELL DRILLERS, INC 370 <br /> Information provided with this appli N • true and • . best of n towledge. <br /> \ Conmrents: _ • <br /> Signature of Owner <br /> or Designated Agent: 2 • <br /> Date Signed: J 9 3 <br /> FOR COUNTY PERMIT USE <br /> Date Received DNR Variance Floodplain Delineation Flood Protection Elevation <br /> ❑Approved ❑Floodway. flimsl <br /> •3(z-(/13 <br /> ❑Disapproved ❑Flooditinge <br /> 19,Requested ❑Other <br /> Not Required — <br /> Permit Fee Approximate Surf a Elevation of Well <br /> Paid ❑Not Paid � � <br /> �1 films] <br /> County Sanitary Permit No. Special Well Casing Requirements: UYes 'No <br /> Distance to Nearest Landfill: �Z° _ft <br /> Permit Application is: , 1G ranted ❑Denims+ <br /> Comments: <br /> permit shall remain valid until: _ it A. <br /> . -.4 fliffLd <br /> Signature of Administrator; 1l <br /> 3/z-7 r3 <br /> Date Signed: <br /> FOR COUNTY IN_ SPECTION USE <br /> • <br /> Casing is: Sealed: <br /> Inches in Diameter Comments: <br /> Inches Above Grade ❑Yes ❑No <br /> i <br /> Date Inspected: <br /> ❑Before ❑During ❑After Construction <br /> By:(Initials) Signature <br /> THIS APNLIUA I ION MOST INCLUDE-AN-8 172 z T1"-SITE PLAN SHOWING-fF IE VVECL-P+ND-SETBACKSTO ALTCONTAWIINRTION S <br /> G(\ / LV/ C6-17 COUNTY 32676 <br />