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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> Department of Natural Resources Form 3300-76 5-87 <br /> APP2CANT COMPLETE DNR Use Only For County Use Only <br /> int Original Application Reed County. '. ..• IDate ( 3/.2-- <br /> ❑ Reapplication(Explain) gyp. Approx.Surface Elevation of Well 9/� MSL <br /> ost-Emergency(Explain) Faced County Well Location_ <br /> ' ed ❑ Driven Point ❑ Other SID Permit Number 10.S-. a, �9a-ao9 - <br /> ivate Well ❑ Noncomm ty Well <br /> Well Serves: Indicate location of proposed well,private sewage system,direction of slope, <br /> Descri ( x.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.) Suggested Scale: 1 square-10 feet. <br /> • <br /> ❑ New replacement ❑ Reconstruction/Rehabilitation , , , .... <br /> �j�j� `, b ` Of ell onstructe,,d In 1,9� ? •_ <br /> Reason For Well 13�/t/ ((,C.✓� i� /�1//�LJ.f✓iLU .. _ .. .. .. ..... ... .. ... .. . .... . :: ::: ::: . .. <br /> Property Owner ;.... ....�.... ...i...� >... .... . <br /> _ i� <br /> pro Mailing Address <br /> l }A� —/ : • <br /> • ,State,Zip Code elephone Number ..t...• . <br /> a ' . z."d/l ' X3_3/ ) ::.. : : . . • • • <br /> Well Loc:,,j• :The square represents a section of • : • • • • • • <br /> land diet.: into 40 acre tracts. Mark the •• i <br /> location of the premises in the section. . ; . M • • <br /> /yC 1/4 of /VP- 1/4 of Sec. 1 , i...:....;...:....i...i... ...... <br /> T. = N: R. / (❑ w i... .. ;.... ... ... <br /> .. i <br /> Lot# dock# . . . <br /> Subdivision Name ifr4 <br /> ❑ City: Street Address ,fi n � `/ ,. • : <br /> gal Town Of: JjC i / '/(%�l/ C''� ? <br /> Well Located On Highest Point Of Property 0 Yes No °W)14// 9� <br /> Distance In Feet From Well To: ,', 1I.-• <br /> Nearest Well Clearwater/foundation Drain....... Silc?.Ayr.c1/2th <br /> Landfill f 0/20 Foundation Drain To Sewer Type Silo'f- <br /> f 2., Building Overhang Bld Drain Barn Gutter <br /> 4'2c Septic Or Holding Tank '.or EQ ❑ Other Manure Pipe <br /> 1' "b Sewage Absorption Unit 16r Bldg.Sewer ❑C.I.or EQ ❑ Other <br /> Nonconforming Well Pit essu rized❑ 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 /> Shoreline/swimming Pool Wastewater Sump <br /> ••••/O Downspout/yard Hydrant Paved Animal Barn Pen <br /> Privy Unpaved Animal Barn or Pen COUNTY INSPECTION USE <br /> W- Cons. ,•1' Name ('•: t) License Number Number Of Use of Well Location Complying <br /> / ► Existing Active Wells �Fl j�%,/T�Yes ® No ❑ <br /> /1* • I t/.�. /J . . .f <br /> Si?•azure Of Co • • / Existing Unused Wells Yes ❑ No ❑ <br /> // .I• a .A �I" \�i'L1r/ : 'M'. lar ,/ Wells To Be Abandoned <br /> COUNT ' 1/ USE n <br /> Permit: Granted ® Denied ❑ DNR Variance: Requested ❑ Site Inspected ❑ Before ❑ During -After Construction /Z/` 2_ <br /> Fees: Paid Not Paid El I Approved ❑ Disapproved El Q Date <br /> Tax Parcel Sanitary By (Initials) /&/(t-- Signature.��C: ,' <br /> or Lot No. Permit# <br /> ALIC •Qf System Essential As Sketched See Drawing On Back ❑ <br /> (` e t_/_ ` Casing Is Inches Diameter Sealed Yes �c No ❑ <br /> 1 <br /> Signature Date & 2 4 f' Inches Above Grade <br /> Comments(Reason for denial/condition of existing well,new well on <br /> highest point of property,field notes):.1N/S Wtxu.. '. A werx, Ccenfmf• rLL _ CAS/.r a /nits._'FWD /a <br /> , - Ltsts'2 35' ANC cr.:An-V s,s fot.Ace, 'T PA, inu r cek4 c_ A-rn McGAr,t <br /> Ac7 Sa, D iciAter £t4 RFT CeAscr `t'8 A-1025 Pawl( Td t)SL.- CaNSTZLtcN- <br /> COUNTY <br /> v <br />