Laserfiche WebLink
State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> Department of Natural Resources Form 3300-76 Rev. 8-97 <br /> I County Well Permit No. County <br /> W PFRV EL. ao/b -O©I <br /> ."1-/I) <br /> INFORMATION TO BE COMPLETED BY THE APPLICANT <br /> Prope wner(Print) Telephone Number Site Development Plan(If required by the County) <br /> Building Plan or ❑ Sanitary Plan or ❑ Other <br /> om Buglass (608) 320-8074 Attached Attached <br /> Mailing Address(Print) Well Location in Town U City U Village i <br /> 5075 Lincoln Road OF_Oregon j <br /> City State Zip Code Well Street Address Fire No.(If available) <br /> Oregon WI 53575- Lincoln Rd 5075 <br /> Well Type Subdivision Name or Certified Survey Map No. Lot No. Block No. 1 <br /> 0 New ❑ Replacement ❑ Reconstruction <br /> Well is a Tax Parcel No available) <br /> 0 Drilled El Driven Point ❑Jetted ❑Other 1 <br /> 042/0509-141-8500-1 'Ad ,.. <br /> Current number of wells on property: 0 Gov't Lot No. o '/ of NE A of <br /> Number of unsafe,unused or noncomplying wells to be abandoned: 0 Section 1 4; T. 5 N; R.9 51 E ❑W <br /> Designated Agent's Name(Print) Well Constructor(Print)(If known) License No.(If known) <br /> ELLYN REDEKER SAM'S ROTARY WELL DRILLERS, INC 370 <br /> Information provided with this application is true and correct to the best of my knowledge. <br /> Comments: _ <br /> R E( E I V E D <br /> Signature of Owner v <br /> or Designated Agent: <br /> Date Signed: i i--'7'1 LP JUL 1 1 2016 <br /> FOR COUNTY PERMIT USE Public Health MDC <br /> Date Received DNR Variance Floodplain Delineation Floa itbf i 1°I t>tiediti' <br /> ❑Approved ❑Floodway -age <br /> i� 1(C/ ❑Disapproved' ❑Floodfringe <br /> �❑,Requested ❑Oth er II <br /> )12I„N t Required <br /> Permit Fee.'/eQ, r �� Approximate Surface Elevation of Well <br /> Paid ❑Not Paid (DSDft./ms1 <br /> Countyy SSanitary Permit No. d 16.e Special Well Casing Requirements: LJY es o <br /> 1 �)0 t 6 1I Distance to Nearest Landfil /:2d ft <br /> Permit Application is 111 Granted anted Hed --- <br /> Comments: <br /> This permit shall remain valid until: l q <br /> ....... <br /> ....... .4,, <br /> Signature of Administrator: <br /> Date Signed 1 /1' L(Q <br /> FOR COUNTY INSPECTION USE <br /> I Casing is Sealed: <br /> Inches in Diameter Comments <br /> I <br /> Inches Above Grade ❑Yes ❑No <br /> Date Inspected: <br /> ❑Before El During <br /> El After Construction <br /> By:(Initials)__ Signature <br /> i' <br /> I HIS APPLICA I ION MUS I INULUDE AN b 1/2 x 11"SI I E PLAN SHOWING I HE WELL ANU SE I BACKS 10 ALL CON I AMINA I ION SOUKC <br /> COUNTY 40456 <br />