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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION <br /> B •nt of Natural Resources Form 3300-76 Rev. 8-97 • <br /> Cot�y WeIIFe=mtkNa, # ( Cotuttr <br /> INFORMATION TO BE COMPLETED' BY THE APPLICANT <br /> Property Owner(Print) Telephone Number Site Development Plan(If required�County) <br /> c' ❑ Building Plan or Sanitary Plan or ❑ Other <br /> I ; <br /> t ) �f( ) Attached Attached <br /> Mailing Address(Print) Well Location Town <br /> 0 City 0 Village <br /> A ?-fir ci•f'.{/� C • OF I'-)Ic.6 ti tc,<AA S• <br /> City • State Zip Code Well Street Address Fire No.(If available) <br /> Il.. (,,-• vf• yr e <br /> Well Type Subdivision Name or Certified Survey Map No. Lot No. Block No. <br /> New ❑ Replacement ❑ Reconstruction ( 7 <br /> Well is a Tax Parcel No.(If available) <br /> Drilled ❑ Driven Point ❑ Jetted ❑ Other <br /> Current number of wells on property: C-' Gov't Lot No. ortu/L 'If of SA) !4 of <br /> Number of unsafe,unused or noncomplying wells to be abandoned: (/ .i Section r' • T. (c N; R. QJ E ❑W <br /> Designated Agent's Name(Print) Well Constructor(Print)(If known) License No.(If known) <br /> Information provided with this application is true and correct to the best of my <br /> knowledge. Comments: <br /> Signature of Owner (' <br /> or Designated Agent: /}; <br /> Date Signed: /(./�WG-''t <br /> FOR COUNTY PERMIT USE <br /> Da rved DNR Vanance Floodplam Delineation Flood Protection Elevation <br /> ❑Approved ❑Floodway �� . <br /> Perna Fee ❑Disapproved ❑Flaodfnnge Ap roximat Surface i ratwn of welt <br /> ❑ lbeguested ,�Qther <br /> Paid ❑:sot Pall mint Required ft tmsl <br /> county Sanitary Fermtt No_ <br /> Special Weil Casutg Regat(ements � ]°es ,� Na <br /> D>sta>1Ee tp Nrarest Landfall ,. �: ;� ft , ; <br /> Permit Application is Granted t❑Denied Counts. <br /> This ri ft shah remain Yal d until = <br /> tgnattrre of Adtnm>$ttator <br /> - <br /> FOR COUNTY INSPECTION USE <br /> Casing is; $4alCd Y <br /> Indus m Diameter r ' <br /> d Yes .❑No Cotnaients <br /> Inches Above Grads <br /> Date Inspected <br /> ❑Before ❑During ❑After Construction <br /> By.(initials)_ .. Signature <br /> PROPERTY OWNER <br />