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DANE COUNTY 1202 Northport Drive <br /> Madison, Wisconsin 53704 <br /> � ENVIRONMENTAL HEALTH DEPARTMENT!'�C�2.:���,y� 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) <br /> Hope Rod & Gun Club Peter H. Burno & Associates <br /> Owner Driller/Pump installer W.D. 607 <br /> % Dick Belshaw P_I. 2929 M.P. 1017 <br /> Address License No. <br /> 251 N. Fair Oaks Ave. DeForest, Wisconsin 53532 <br /> Address <br /> Madison, Wisconsin <br /> Phone 249-4757 Date Phone $346_3226 <br /> Location of water system: <br /> Township Blooming Grove NE _Y4; SE 1/4; <br /> Sec. 15 ; Subdivision <br /> Directions to locate property 12 & 18 to Brandt Rd. , South to Siggelkow Rd. , <br /> West to site. <br /> DESCRIPTION <br /> 1. Premises 2. Use (describe exactly as 1-family home, <br /> Lot size ft.x ft. <br /> motel, etc. <br /> Acreage 14 =MC InftifrtrXMAX Club House <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 6 in. sched. 40 18_.97 PPF <br /> 6. Type of grout&method of placing As per ehapter 162 <br /> I certify the information in this application is true and correct: <br /> A— ' _ <br /> ignature of drill_ 1•ump installer <br />