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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION ' Department of Natural Resources Form 3300-76 L F5-87 -o lc-�� (o LICANT COMPLETE DNR Use Only tt��qq�r�� For County Use Only Original Application Rec'd %�•itfe- 111'7S7�i9 Reapplication(Explain) gyp. Approx.Surface Elevation of Well Q''MSL • Post-Emergency(Explain) Fackl L:ounty Well Location 1! Drilled ❑ Driven Point ❑ Other SID Permit Number l0331c 1 al-'0370 'j Private Well ❑ Noncommunity Well , Well Serves: Indicate location of proposed well,private sewage system,direction of slope, Describe(Ex.home,restaurant.church.etc.) bldgs.served,other bldgs.,existing wells,surface water body,buried fuel tanks, neighboring waste sources. Well has ho y service connections? (indicate No.) Sueaested Scale: 1 souare-10 feet ❑ New Replacement ❑ Reconstrucdon/Rehabilitation : : : ,...4...........•iii i ... ...` ': : • Of Well Constructed In 19 52_,...- i.... • i • • i. .i. i. •...4...t....i i..•%••••s...;....... • • •i•. Eason For W •UgNmieelt-V 11EITAYUDI 4 CEVI311 4/ ▪ . . . . . • • • • • • ' : : : : • • •h 1 dorgc <............. _.. ..._. ....... ' i...1....1...•n Owra's Ri r• a.. 1108 •rl�sor) : : : ... • ' . : : : :...� . . . C' ,State,Zip LCode/ ` Telephone'Nuumbbs .: ' ' ' •' . i i i ': : •i••• i•••i••••i•••i rshoill/rLT ,5 1 1V (yl/)UV,7°3 • :..i. .i. i .t.. • • • .i...i. .C).:... ` . . . .i....i...i , Well Location:The square represents a section of ..,_ . . M• . ' �� ' ,, .. .. ... land divided into 40 acre tracts. Mark the �� ' >< ▪ . ...... ../pis'..% ....;. location of the premises in the section. • .!..4.4444.i...:.-0.. ....,0...;444i No 'i"'°.0, `'...i .'...i a Eit 1/4 of rvw 1/4 of Sec.3,• . ...... .. .i...... ... .t. _ . .:a... .....i:.. i... .{ T. G 11�� ]E W i• . •i. • ..t.. t ri5•Lot# I lock# 'Subdivision Name i : . : t. -^i"' i .. • ... .......• V • .. • 4 t�• ..`! ,... •. D City: Street Address ry .4. .. . Village: ..i........ .. .. .'... ....... .. 1 . .... . . ... .... ..... .. Town Of: �,ld.�.Y1p�. o.... Well Located On Highest Point Of Property ❑ Yes Ergo Distance In Feet From Well To: S/e Nearest Well /4 Clearwater/foundation Drain....... __ Silo 4& Landfill e' Foundation Drain To Sewer Type Of Silo /- --ei-amv Building Overhang .4 Bldg.Drain • 1 Barn Gutter t(-' ' Septic Or Holding Tank 0 C.I.or EQ ❑ Other __ Manure Pipe. .t Sewage Absorption Unit. 4 r Bld ewer ❑C.I.or EQ ❑ Other eel Nonconforming Well Pit Unpressurizecl❑ Pressurized( r� A Manure Pressure Pipe Buried Residential Oil Tank 1_ Collector Sewer Z ,,% Other Manure Storage Buried Petroleum Tank s4 Clearwater Sump h�i\4 _.!ts__ Other NR 112 Waste Sources /l•( Shoreline/swimming Pool �i Wastewater Sump Y 0 440 Downspout/yard Hydrant ,if Paved Animal Barn Pen. ... ,., Privy Unpaved Animal Barn,• 'en. COUNTY INSPECTION USE " 1 tor s `ame .r.. I{ , ....:-. 1 lseo "ell Location Complying • .AO i.ant(/ _'1,, -- . Ire ••tmg cove "e i: f�Ia. . . Yes 0 No ❑ Sign • ., .�.; e s:te tgn r E ' ling Unused Wells Yes ❑ No El�i J - •.- W=i;To Be Abandoned Permit Gated 11 s- -, ❑I DNR Variance: Requested ❑ Site Inspected: ❑ Before ❑ During After Construction / -5°C ' Fees: Paid ►� . Paid ❑ Approved ❑ Diseci,lroved ❑ y Qom( e Tax Parcel Sanitary " -' 3 5 C By (Initials) L O Signature /Civil..., or Lot No•0Fi j Z 032-8(22,-- Permit#87-05'3 System Essentially As Sketched See Drawing On Back ❑ I/. , `, ✓/J _ IF E.-4P? Casing Is (p Inches Diameter Sealed Yes gl No ❑ Signature & /6- Inches Above Grade Comments(Reason for deni. condition of existing well,new well on highest point of property,field notes): '-- _ — X . (- • / in ]P it >;° ° ...f't 1A) i u,' "At 1 A r c.eAL.64 4.4.°.doe0'..C14 ', ..o.1,14'��4A4444 I on 4.4110-"t .4: COUNTY