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-State of Wisconsin COUNTY/STATE WELL.LOCATION PERMIT APPLICATION <br /> Depmtm it of Natural Resources Form 3300-76 Rev.8-97 , <br /> Iiatj W Permit N <br /> .e A a53 —0rVo <br /> INFORMATION TO BE COMPLETED BY THE APPLICANT <br /> Property Owner(Print) Telephone Number Site Development Plan(If required by the County) <br /> Plan Plan Other <br /> Peter Simon 0 AAuachod c ❑ <br /> Mailing Address(Print) Well Location 0 Town U City U Village <br /> 2780 Brooks Ridge Dr <br /> RY State Zip Code Well Sheet Address (— Fire No.(If avaiW le) <br /> Sun Prairie WI 53590- 7197 Welford PI. /14'-'-' <br /> ell Type Subdivision Name or Certified Survey Map No. Lot No. ' Block No. <br /> R New ❑ Replacement ❑ Reconstruction Winfield Estates MAY - 3 1, i ! /■)4— <br /> Well is a Tax Parcel No.(If available) <br /> ® <br /> Drilled ❑Driven Point ❑Jetted ❑Other 012/0911-183-0243-0 <br /> Current number of wells on property: 0 Govt Lot No. or nW V. of SW V. of <br /> umber of unsafe,unused or noncomplying wells to be abandoned: 0 k . .._T. 9 N; R 1 ®E ❑W <br /> Designated Agent's Name(Print) Well Conmvdor(Print)(If known) License N .(If known) <br /> ELLYN REDEKER SAM'S ROTARY WELL DRILLERS,INC ., 3 0 <br /> Information provided with this application is true and correct to'. . of my knowledge. : 1 _ „_ , l <br /> Signature of Owner . L v + <br /> or Designated Agent: t !�.k_��� j <br /> Date Signed: / • —N-014 C 1- -- - -- _I <br /> IDeteFOR COUNTY PERMIT USE <br /> Received DNR Variance Floodplain Delineation Flood Protection Elevation <br /> ❑Approved ❑Floodway /3A-1 <br /> Noi Required _ <br /> Fee Approximate Surface Elevation of Well ftimil <br /> aid ❑Not Paid "�� <br /> County Sanitary Permit No. Special Well Casing Requirements: UYes )&o <br /> y.S S sm O3-6zp q/q Distance to Nearest Land6p// <br /> m 7 ItzrergraS <br /> Permit Application is: / <br /> This permit shall remain valid unit: e---1.-19 A i <br /> 0 k _ Ter.„....107' <br /> Signeture of Admivar o: c <br /> Date signed: <br /> 'OR COUNTY INSPECTION USE <br /> ,casing i Sealed: <br /> Inches in Diameter Caamneats: <br /> �A_ Inches Above Grade ❑No <br /> ,Date Inspected: i 7?./0S------ <br /> ❑Before ❑During Vi <br /> Icy:(Intial y_ Signature tat <br /> I Nib ANF'LIGA I ION MUb I IN UUt AN I3 I 11-51 t PLAN 51$OWING I Nt WELL AND St I SACKS I U ALL DON LAMINA LION 50UftGtS <br /> COUNTY 13312 <br />