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State of Wisconsin COUNTY/STATE WELL LOCATION PERMIT APPLICATION
<br /> Department of Natural Resources Form 3300-76 5-87
<br /> kPELICANT COMPLETE DNR Use Only For County Use Only
<br /> Original Application Recd Co (3v �DateRecd 1!_$_$c�
<br /> Reapplication(Explain) P Approx.Surface Elevation of Well 980 MSL
<br /> iePost-Emergency(Explain) Facid ounty Well Location
<br /> Drilled 0 Driven Point ❑ Other SID Permit Number 1.33 1 ,J Q$9-G37�.
<br /> Private Well ❑ Noncommunity Well /70 m '
<br /> Well Serves: Indicate location of proposed well,private sewage system,direction of slope,
<br /> Describe(Ex.home,restaurant,church,etc.)
<br /> bldgs.served,other bldgs.,existing wells,surface water body,buried fuel tanks,
<br /> g
<br /> / neighboring waste sources.
<br /> Well has how many service connections? (indicate No.) Su nested Scale: 1=tare-10 feet
<br /> Ni.(
<br /> New ❑ Replacement ❑ Reconstruction/Rehabilitation : • i..,•j.•.s..• ..•�,,, ,.•:
<br /> Of Well Constructed In 19 t
<br /> Reason For Well Is AllPii : : : i
<br /> • OA ! .1 ♦ X77 : : t :
<br /> 41,, • er .+-i. -i. i•••i i•,. ...•••i....
<br /> ie�z .r ,_Sinn : : • : : •
<br /> Property g a • :'. ./or: : : : i
<br /> /A27 cc ��__ E
<br /> City,State,Zip Code Telephone Number i,•. .•.;•,.' s
<br /> L ....•••I.... ...........a j...•. .,:• .,...•:•,.,i...i....i..,i,...i,,,i,,,.i.,,i.,,, ,
<br /> Well tion:The square represents a section of 1: .. .
<br /> land divided into 40 acre tracts. Mark the
<br /> • ,�'�.. ... . . ..,�4....:.,),.._... .i..,4....;...t....:..
<br /> location of the premises in the section. i r••;• . • •• ,,h • V�. . • •
<br /> •....•..•.. .,. ....y....: : .tk . ..i....:� . E • . . i...
<br /> �� 1/4 of 7L4J 1/4 of Sec. • : : 1,..(1,:c., c....t...1- i... ...d"'. ...l...i.... ..X
<br /> Lot# lock# Subdivision Name • : : : : :•
<br /> 4 I : .. . i...;.......•:....i. . Yi ;,,.•. ,-.ss...«....,,•«... .......
<br /> City: street Address it/A7 a.4.
<br /> El Village: Or wry �Guh x
<br /> plyTown Of. to
<br /> Well Located On Hig est Point Of Property ❑ Yes El/fro
<br /> Dist ce In Feet From Well To:
<br /> Nearest Well �il Clearwater/foundation Drain Silo
<br /> Landfill Al( Foundation Drain To Sewer Type Of Silo
<br /> I- Building Overhang
<br /> AA Bldg. Drain Barn Gutter
<br /> Septic Or Holding Tank �r C.I.or EQ [] Other �_ Manure Pipe
<br /> 4.0'10 Sewage Absorption Unit. d-r Bldg.Sewer ❑CI.or EQ 0 other
<br /> Nonconforming Well Pit ❑Unpressurized❑ Pressurized Manure Pressure Pipe
<br /> Buried Residential Oil Tank Collector Sewer e ....... Other Manure Storage
<br /> Buried Petroleum Tank Clearwater SumpL Other NR 112 Waste Sources
<br /> Shoreline/swimming Pool Wastewater Sump
<br /> po , Downspout/yard Hydrant !/ Paved Animal Barn Pen.
<br /> Privy /tt Unpaved Animal Barn or Pen COUNTY INSPECTION USE
<br /> ll Construc • 's Name (' '• License ►umber Number Of se of Well Location Complying
<br /> Si ,a/ /41 110-Ak 1 - A misting ctive ells Yes u No ❑
<br /> Signatur 1 or,/ sate igned Existing Unused Wells Yes ❑ ❑
<br /> 1 i-i-Pc Wells To Be Abandoned
<br /> 0 ' 'ERMIT L SE
<br /> Permit: Granted' Denied ❑ Variance: Requested ❑ Site Inspected ❑ Before ❑ During ❑ After Construction
<br /> Fees: Paid Not Paid ❑113NR
<br /> Approved ❑ Disapproved 0 —�
<br /> Tax Parcel Sanitary By (Initials) ——— Signature
<br /> ac4•e446••.210 Sn 5-1/o g n b Permit#89-OS 9'l
<br /> System Essentially As Sketched ❑ See Drawing On Back ❑
<br /> rtiaZ.D. /j-9-$7 Casing Is Inches Diameter Sealed Yes ❑ No ❑
<br /> Signature Date & Inches Above Grade
<br /> Comments(Reason for denial/condition of existing well,new well on •
<br /> highest point of
<br /> Ty
<br /> ,field notes): 1', , °7— q
<br /> •
<br /> /CAI 1MTV
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