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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> Department of Natural Resources Form 3300-76 5-87 <br /> PPLICANT COMPLETE DNR Use Only For County Use Only <br /> Ori'ginril Application' Recd County„am) 1%D!B� �3 <br /> Reapplication(Explain) Insp. Approx.Surface Elevation ofWell900 MSL <br /> ❑ Post-Emergency(Explain) Facid Lounty Well Location <br /> ral Drilled ❑ Driven Point ❑ Other SID Permit Number W Aa.1 a D 93 a t!/e) <br /> Private Well ❑ Noncommuni ell � . <br /> Well Serves: £io ,tomP T'r ,M e Indicate location of proposed well,private sewage system,direction of slope, <br /> Describe z.home,restaurant church,etc.) bldgs.served,other bldgs.,existing wells,surface water body,buried fuel tanks, <br /> / neighboring waste sources. <br /> Well has how many service connections? (indicate No.) Sugeested Scale: 1 square-10 feet. - , <br /> f -New Replacement ❑ Reconstruction/Rehabilitation <br /> • :.-- ... <br /> fiZ Of/W�ell Constructed In 19 { :Reason For Well Is G!7 O#0ST. . i t i •• i .. ' <br /> property * ;.... 5 ....:.. ....i .....i... • �:i <br /> --.gym S T' p.. .... .. ... ... ....... ... .. . ...�... e•Property Owner's Mailing Address � ..,...r.. <br /> 2'995 v i „„tyy A -Ba :/�` .: rte: pis <br /> Telephone Number •••''' -•t- "'� ... '" y <br /> City,State,Zip Code eP • • ' <br /> f}GEC Ot,uh 53521 641'222-3s-2g •..:...:....:.... ...:... ... .. • <br /> Well Location:The square represents a section of i • : : _ ' : • <br /> land divided into 40 acre tracts. Mark the : : : t i <br /> location of the premises in the section. ` • • ' ;•+.i--- ` i..../...i....i...i <br /> A : <br /> 1/4 of 1/4 of Sec. ....:.............}. <br /> T. _._N; R. 1_,L I E D W i. . . .. ... .. .. ..� <br /> • <br /> Lot# Block# Subdivision Name : . • • • <br /> D i :� . . v .. .. <br /> City: Street Address o = • . 3. <br /> ❑ Village:^' EC O" 2 946 CdM� /4 n 4„4:°4?/7!),..i___gt • . . . . <br /> IS Town�f�TJ ijf LZt'1`r� • <br /> Well Located On Highest Point Of Property ® Yes ❑ No r em° l <br /> Distanch In Feet From Well To: <br /> �, Nearest Well Clearwater/foundation Drain Silo <br /> Landfill / Foundation Drain To Sewer Type Of Silo <br /> • Building Overhang `7 t) Bldg. Drain Barn Gutter <br /> - ' Septic Or Holding Tank , tIS C.I.or EQ ❑ Other Manure Pipe. <br /> .. Sewage Absorption Unit 70 Bldg.Sewer ❑C.I.or EQ ❑ Other <br /> Nonconforming Well Pit ®Unpressurized❑ Pressurized Manure Pressure Pipe <br /> Buried Residential Oil Tank. # Collector Sewer Other Manure Storage <br /> '..— Buried Petroleum Tank Clearwater Sump Other NR 112 Waste Sources <br /> Z Shoreline/swimming Pool Wastewater Sump <br /> 3° Downspout/yard Hydrant....... Paved Animal Barn Pen. <br /> Privy Unpaved Animal Barn or Pen COUNTY INSPECTION USE <br /> We Constructor's e (Print) License Number Number Of Use of Well Location Complying <br /> L(CLCG.S ,ZNC 3 / Existing Active Wells ��5 Yes ' No ❑ <br /> Sj�ature Of Well Cons for Date Si ed Existing Unused Wells Yes ❑ No ❑ <br /> ����"/^ �� /0�3�y 3 Wells To Be Abandoned <br /> C P IT USE <br /> Permit: Granted Denied ❑ Variance: Requested ❑ Site Inspected: Before ❑ During t ter Construction /r 3'74" <br /> Fees: Paid Not Paid ❑IDNR <br /> Approved ❑ Disapproved ❑ ��� <br /> Tax Parcel Sanitary By (Initials) _Z-� Signature �� <br /> or Lot No. Permit# <br /> /� System Essentially As Sketched , See Drawing On Back ❑ <br /> ,..„e„, �/ /6 /e^ 5:3 Casing Is (a° Inches Diameter Sealed Yes NIS No ❑ <br /> / Signature Date & /9 Inches Above Grade <br /> Comments 'eason for denial/condition of existin:well,new well on <br /> highest point of property,field notes): / / <br /> 11_:.•/_ '/—.. ---_--_-' ..; %M�/����rsM �, . <br /> COUNTY <br /> 'ter <br />