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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> .Department of Natural Resources Form 3300-76 Rev. 8-97 <br /> .'+s.'!.•..-YMR....i::}1r :{.�1?:.,,,,.:::.:::.::.:..:.::::.:::::...:::::.�,::,. <br /> INFORMATI N TO BE COMPLETED BY THE APPLICANT <br /> Property Owner(Print) Telephone Number Site Development Plan(If required by the County) <br /> �(( ( ) ❑ Building Plan or -Sanitary Plan or ❑ Other <br /> -aA /u s-Trrf.)► f/C 's,IhJIs, Attached Attached <br /> �g Address(Print) Well Location ®'flown ❑ City ❑ village <br /> /1/i Ghtrf,Cf'e/d Ct !� °' I n)! <br /> City( State Zip Code Well Street Address <br /> Fire No.(If available) <br /> fuh /3f-�/l�Js C. ' F..7?f) 67ey /It6�i� ii • <br /> Well Subdivision ame or Certified Survey Map No. i ot,No. Block No.airoil <br /> Replacement ❑ Reconstruction tr�it1L+ !/'<? lstat'/ s/ <br /> Well is Tax Parcel No.(If availlele) <br /> Q-Drilled ❑ Driven Point ❑ Jetted ❑ Other <br /> —v7ll-3cs -- - 14)53.(— <br /> Current number of vigils on property: � Gov't Lot No. of .41t4 of <br /> Number of unsafe,tamed or noncomplying wells to be abandoned: D Section 31 ; T.f N; R. If IRE ❑W <br /> zarte.id Ge/44/714 • • <br /> Agent's Name(Print) Well Constructor(Prlint)(If known)- License No.(If known) <br /> Information provided with this application is true and correct to the best of my <br /> knowledge. Comments: MAY <br /> Signature of Owner <br /> or Designated Agent: �� <br /> Date Signed: _ 7/fo%y <br /> FOR COUNTY;PERMIT USE <br /> ................::.........::::.. <br /> :'<:::>jj is ;<' `^ ii:'< (J :i:`ii:is ........ ..:.....•........ ............... . a. ...:. .:':: ....... <br /> ::: .::;::: :. . :. :: : Wei .. <br /> .J...:.:.......:.............:::...:: .......};. ..\...I':;'J":.::.::::::.,.:...\..:,' „,V,;/.:::1.KJ:.MW,.K.:Y.M".V:°C::::.'°:e41......M.:,....::....:....../YA\J'.\\.t. ..........�.:.:..::................: <br /> 1t <br /> • <br /> ....:::.:. <br /> ...:.:.:..:: <br /> ,:,.:.::::,..,:.:a ,;, :::,.:.:;....:................... <br /> :;::;:; ::;::;::::;::;::: ':;....i::3sf :>"',.''i?;iz'::."':i:>`:; ii 'Er°.`iii;;?' °� :;. . _.•:..;;<;. <br /> ... • :i:i:.,-::ti':Y:�" ::. ::;:::. :»>;;:.;;:-.:'a;..:..c>:i::;o::.ii::v;::^>::" �::.:;;:.;:::i::ir.:i:.:.::>ii.:isi,i:�>:ai>iz::;irr::;,,:;:::¢,;.:::;•.,.:::;:.;:>:; <br /> ....................... .:.�.:..�::::::.:.:::::::::::::::::.,. ............ :.... .:....,,.. :::.::a.A:;:;.:::::':..:.... .wr.a*u•:«:%`deb b. '�w.e 1'W.'•..:�. <br /> .. ��:�1¢ tots........ � : .. ... '......:.. <br /> R I�r�i . . : ti ..�i...EcTION Vita 'it.: :.:...:..:.... .... ..... <br /> ...:.:::::::... <br /> .. .,......::. <br /> :.....:....: <br /> . ...:.:.:::;. <br /> .....:::::... <br /> .:.........::. <br /> :i?.l:_EiEb'ii':?; `i'yir?: :;::%Y;:}i?i.SG'ii?}``:j;%:5`[:;i;!•,i ��'}"'fY'.;::iii�%' :i£ <br /> ............:.:....................... <br /> x <br /> •::}.';}:}}}}:}}::::::::::::::`::}}`::is y.:•::}•>:-;::;;:.:�::•..:;:>:.::::>::.:>:.r>:.:::.;y.::..:c;:<.;>;;::::�:.,.:::•::.::.::.>;:;:�.::c::::>:�:%}: <br /> .:�'....•.-.--,• r Ali <br /> :'{';:;.�:?•;::n.::::::r::::.� 'v::'::�::::iiii::isi;4i'.:::ii:?::H:::::::::::::::f::}v: <br /> '� •Y!;::nii;.::�-:.�i';:i.:::..:::.:'..::. .:ii:..:.i;;;iiiiiii;;iiiiT:.iii:i.isi:.iiiiii;::::oi:i:ic:�:;::v::::::.:'.i:::::::•,�.::::.::::::::.v;..::;::!.: <br /> :.ii;: :.:..:;�...:.:::.::.:::.:::::::::::.::::.::::.:::......:..........::.::.,.:•::..,::::::...:...::.:.:... .... ::.......................:...i�:}:v::}:S:;;c::::;:::5:::;:::;::i;<i::�:::::::'::;:;:::::::5::5�:5:;::::>ir.:�:. <br /> :...... ::r.;;v;i:�;•:.-. ,�. ... ..�..o-. ......:..::;_:��::::.�-:::;:»n;:.::•:::,.,»:;:ni:;;:.�'•.•.;.':..'•,iry>•rar::'�:r::.rr:::::::::•::::::::::::::.�::..�:::::>:.>:aiii:. <br /> THE APPLICATION MUST INCLUDE AN 81/2" x 11" SITE PLAN SHOWING THE <br /> WELL AND SETBACKS TO ALL CONTAMINATION SOURCES. <br /> COUNTY <br />