Laserfiche WebLink
,oiP INSTALLATION AND TEST REPORT I For Office Uee Dory <br />.~TE~ OF COLCFADC, OFr=1CE OF 1-iE STATE ENGINE=~ <br />' 4~ rcULLi <br />0 - F~ <br />PE:iMIT N <br />UMBEr'T o~ ~~r~i <br />/n1 <br />/ <br />R <br />' <br />" <br />~ <br />~ <br />,JE <br />NAME <br />GLI /~.f <br />llQ1 <br />S I Mrs I <br />SCI n N <br />l) <br />ailing Adtlress ^ ~ ~ v ' 1 <br />, <br />ay, SL lip _, ` ' n ~` r I ~ r•. ~ n uC ~,. <br />Pfione ( p ~ ,Vi'i' i - ' U G~ <br /> E~_ LCCATICN AS DPIU=D: ~,_1/a S~ 1/4, Sec.~~Twp. = ~l <br />, Range j~Cl tal <br /> - <br />DIS ~ ANCES F~GM SEA"'. L1NE5: <br />l7 ft from __ IL{~[_~ Sec. fine. and ~ ~ 0 ft. from _ ~' ~, ~~ Sec. line. <br />-rtam+-sr-sa-~mT ~~~ <br /> UBDIVISION: LOT BLOCK F1L1NG(UNf7) <br /> SIRE=i ADOF.ESS AT WE'1 LOCATION: <br /> ,n/1 <br />UMP DATA: Type S ~b mo r•g~b1~. l„ rr~ oar Installation Completed I r 1C~1"~'h ~ ~ - ~ ~] <br />- <br /> Pump ManufaGUrer <br />~`-, o + \r1 C Pump Model No. ~ D n ~-F <br /> esign GPM LOO az RPM ~~irj0 , HP Z~ ,Volts ~/h0 ,Full Load Am s~~, <br /> ump Intake Depth ~fkU Feet, Drop/Column P?pe Size Incites, Kind ~~-F~ <br /> D01710NAL INFORMATION FOR PUMPS GREATER THAT 50 GPM: <br /> RBINE DRNER TYPE: ®Eecsic ^ Engine ^ Other <br /> Design Head ~Fn feet, Number tlf Stages~_, Shaft size ~ inches. <br /> THEa EOUIFMENT: <br /> Airline Installed ^ Yes ^ No, Orifice Depth fL MonRor Tube Installed ^ Yes ^ No, Depth iL <br /> low Meter Mfg. Meter Serial No. <br /> lons, ^ Thousand Gallons, ^ Acre feet, ^ Beginning Feading <br />eter Readout ^ G <br />al <br /> ~~ <br />II-- <br />eST DATA: tbl Check box if Tess data is submitted on Supplemenrd Form. <br /> Date -I -47 ~~~rn ~ <br /> Tots! Well Depth cZ0 Time [I c._rs, _1~_.QL~ <br />tatic L.=vel Rate (GPM) / r~ ~ /~ <br /> Pumping Lvl. ,~ !ten ~ ~ (~ 1 ~1 <br />7 <br />~y <br />ate Measured-I l <br /> I <br />' <br />L <br />ISINFEOTION: Type ~-F ~ n Amt Used y f <br /> ater Gualitv analysis available. ^ Yes ~ No <br />. ~emarks <br /> <br /> <br /> <br /> <br /> <br /> <br />have read the satemems made herein and know the contents thereof, and that they are true to my knowledge <br />[Pursuant to Szc:icn 2a-a-104 (~3~t/.P..S., tt~e making of falsa statemerrts herein consitutes perjury in the secon <br />,egree and is punishable as a c!as 1 misde eanor.] <br />I <br />~ t <br />/ <br />y <br />/ <br />ONTPACTOP. I V~ ~!~ ,<„/ ~ . Phone 7/L ` ~ (~'~~ Lic. No. y~7 <br />ing Address i~'4"7 '' r r AN~ ~ ~n ~ <br />e/Trtle (P!ease type or print) <br />C <br />r Signature P, •CtifG-i,2~/ [J2EiCir~~ ~ ~ <br />l Date <br />_ !'~ <br />Unn~t2~L)Z'/ <br />~~ ~ci i,n,/ 112;, %,'n c `~ ~~i ~c l ,~L,',~G '`f y7 <br />J J J <br />