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State of rMsconsin Application for Variance <br /> Deponent of Natural Resources <br /> PO Boz 7921,Madison WI 53707-7921 Fom13300-210 (R 10101) Pago 1 of 2 <br /> Notice: Information requested is required for the Department to determine whether or not to grant a variance.Chapter NR 812,Wis.Adm.Code, <br /> establishes uniform standards far me construction and maintenance of water supply systems.Under s.NR 812 43(1),Wis.Adm.Code, 'When strict <br /> compliance Mtn the requirements of this chapter is not feasible a variance maybe requested."Failure to provide all requested information may result in <br /> denial of your application for a variance.Personally identifiable in'ormatlan on this form will be used to administer IM water supply program.Copies are <br /> also available to requesters under Wscensm'Open Recerds law Is,19.31-19 39,Wis.Stats.l. <br /> _Applicant dnformation <br /> Nays;First MI Lost �y Facility Name(if any) <br /> ;r,GZIJ L TA'SO'7 <br /> Mailing Street Address and PO B x duress of well d different than ownef <br /> /6 d T erme Y .ZV�ILl L14G r . z'.,`Ae-j <br /> City Slate PIPCod. City Said IP Codo <br /> asfH SSo3� /-- <br /> Gov't Lot# /.-14. K Sectiom me nship Range E/W City, n o V ila o Counyyt�� <br /> oE kiE J 3 0 i�i� yJ Xwwet�- <br /> Telephone Number Subdivision Name of Number Black Number <br /> Well Construction Informationk <br /> If variance request is far an existing well,include the following well construction information,if known. Induce copy of well report if possible. <br /> Well Type asin De th <br /> {{��'� g p r 7-/ oral Well Depth <br /> ILY Drilletl ❑DrivePoint ❑ <br /> n Other d4 r 5 <br /> Name of Ori°i nal Well Owner Data lConstructed By junique Well Number <br /> nvard f� le 6-S 08 erg^ ;� C(,G 4 � <br /> Vari <br /> Wee,lnformaeo 1 <br /> For what <br /> code requirement(NR 812 Wis.Adm.Code), <br /> o rre nesting ,variance? J�/ <br /> �Il4rti rf P!f/, fr .5 L/�/✓rai1�,�'81Rr1O Y. <br /> What is the requestetl separation distance or construction requirement modifications l ' <br /> 1ln/6 L/oud biL -fa 6'eell-nPX/�S�'J. ✓ / /de�Gk�/suf//�/:fS/yJ�/�c/Jot�4rs�G <br /> (d yGr SO `a t,..a,�,a, (.>f60� �PVr O/ ��V I U/ <br /> I�// / <br /> 7`r'Srdillev Sfb�6f0e S la6G foe- t,.,e// D ' <br /> AVov 7-�OA d a�y <br /> Why is compliance wiN the code requirements not fie Bible? / <br />