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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> partment of Natural Resources Form <br /> 3300-76 Rev. 8-9? <br /> County eB P'----L. i Na <br /> F <br /> INFORMATION TO BE COMPLETED BY THE APPLICANT <br /> Pro Owner(Print) Tel ephone Number Site Development Plan(If required by the County) <br /> � 51�+4 Building Plan or ❑ Sanitary Plan ;: ❑ Other <br /> r}}� c''.4 .'" Col-p4C- e€ ) R t ? Attached Attached <br /> mailing Address(Print) Well Location ® Town ❑ City ❑ Village <br /> 3D �c-I QoA+O OF Std p.a# i al t� <br /> City State Zip Code Well Street Address Fire No. <br /> My h€ ,-tI1a_ <br /> (4)/. 5-31"'"e/ Vi F�cEc)/ �E R0�4,0 <br /> Well Type Subdivision N Survey Map No. Lot <br /> ��,'��t"b,�n <br /> New ❑ Replacement ❑ Reconstruction <br /> ,Os__ <br /> Well is a Tax Parcel • at"1'able) • <br /> Drilled ❑ Driven Point ❑ Jetted ❑ Other o5-q—. �$ t-- � ��� v 1 <br /> Current number of wells on property: o Gov't Lot No. or 0�Sf of 'A of <br /> 1 <br /> Number of unsafe,unused or noncomplying wells to be abandoneds d Section '; T.$ N: R E ❑W <br /> Designated Agent's Name(Print) Wel(.Constmctor(Print)(If]mown) License No.(If known) <br /> F <br /> 5.41>K4.37 QC. <br /> D�x.c,tst mac. 3� <br /> Information provided with this application• true and correct m the best of my u 200.7 CC-449 E Ze)F E. <br /> Igr knowledge. ��,,, - _ Comments:• <br /> Signature of Owner ` u„�/ I' <br /> or Designated Agent: <br /> Date Signed: /$/0Z <br /> •FOR COUNTY PERNIIT USE • <br /> Data,nerved 1]1IIt Vitt3aince PlaodplamDelmcauaa <br /> lid Ftonat <br /> j . <br /> E , ! - E t t�vd+iy xtast• <br /> Permit Pee El lafaod +� ��>i[Qcw• <br /> • 0> ❑cl ter <br /> . fl ri►ci . ,:go .: <br /> ounty h`aerta�l'Petmu I±Io Sp ecthl Well:Casi$g •••eq , < t1 Yes : Na,..„...,..fiL,, .Dt <br /> 1tratfill�• <br /> / <br /> Perunt Appl3cadots la CI» -i- 't .•Niiipetutit shbll redeem v8ltd unlit .. <br /> a� <br /> '�--max'-+,t � <br /> Signature of . <br /> 1).1td r.! ,r. <br /> ►• ' COUNTY INSPECTION USE <br /> L'asb g is a1ed, <br /> j s t Drams cry <br /> bone e <br /> Date . / <br /> t Q <br /> COUNTY <br />