Laserfiche WebLink
Application for Variance <br /> Form 3300-210 (R 10101) Page 2 of 2 <br /> •Sketch the property and location of the mater supply. Include the scale of the drawing and distances to known sources of contamination(for example, <br /> septic systems,gas tanks,drain tiles,animal pens,etc.) <br /> is Show slope arrows from well and contamination sources if lot is sloped <br /> •Attach any extra sheets of other information,which may be useful in describing your situation <br /> S (North) <br /> Al <br /> �OwSG <br /> D o) JWIX. <br /> I fY� <br /> l <br /> F��RE Gr s fiE EP <br /> SITE DRAWING <br /> •OUR regional personnel may inspect this properly to verity information pomaded and to determine cempgmble protection options. You may be <br /> contacted by phone for an appointment,or if more information is needed. <br /> •NO CONSTRUCTION SHALL BEGIN UNTIL THE OWNER OR CONTRACTOR HAS RECEIVED A WRITTEN VARIANCE APPROVAL DOCUMENT. <br /> Writtennodrica0an will be provided of approval or denial with 65 business days of recelpt of Nis applicetic ...,providedbys.NR812,Wu.Adm. <br /> Code. <br /> I cedify to the best of my knowledge the information provided is this application is two,complete,and correct I understand that the information I <br /> provide will be used by the Department to determine if a variance can ba granted and what construction specifications will be required to provide <br /> comparable protection. Ifurther u rstand that in granting a variance the Department does not guarantee acceplable water quality or quantity. <br /> oce� �11� 16 -2- 13 <br /> Owner' Signatur Date Signed <br /> J yen e aI/ AIi Ci."'69.f7 7/S-6'3<S-YS7$ <br /> Name and Address of Well Dollar,"fell Comical or Pump Installer,if known <br /> yAI,L��H,I�AfP�-DATION TO: ' <br />