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% <br /> DA ,RTI,,',ENT of PUBLIC HEAL-t,', •= �C ' <br /> STOCKTO <br /> jX ���� <br /> �L A <br /> I. <br /> ff LL DATA (F) Identafication_-Edi- C.'tZ 1Te11'T6.- 12 <br /> (2) Location_ _ 1412 S. ilutchirs St. , ,_of Kettleran Pare <br /> {3Source of Information Riclhard T. lb-tt -�y2tc_�.?i�Y <br /> bV Anson £_ Sc'=:��edt -_ __-_- <br /> ,, <br /> (3) Number or Name_- __ i p3 `' -r 12 WELL IAG <br /> Date dr:flcd 3-96 _0- ___ IL0 $roam clay----- -- <br /> (4) Loc-ttion: Neighborhood—__-- F s.-Rural _ _ 60 Brown se*ld ��_-- <br /> Sac of lot --- -20 _Bro.Tn clay _--- _ - ----- <br /> Distancc to- Sewer__^—.-__ 10 1 - ak_--sand,__ -- - <br /> Scaagc disposaL__ 25 to store dL-ai120 -Brovn-..c - <br /> Abzndosed well.-- 1-0122 <br /> Xcarest prop-rt) Lne 5 ' - -��o---Sind- ---- - ----- <br /> (5) Housing- T)-pc---- r�rtb Dove ent -_ 2 --Cla.L - ----- -- <br /> Cond,tionroOd _-- -- --- - - - -- - <br /> Pit f lrh depth ars _ -_ ' ------- ____ - -- <br /> y)---�-- <br /> Floor pec Gravel _ - <br /> Drainage -- pair -"---- "" <br /> (G) AeU Depth..— 5001 <br /> (7) Casing Dcpt}► ——__—� __ -------- - --- -- <br /> Diarrcter___ -0 -"-IAa- 20"--- "--Plate----- <br /> 209 <br /> plate---__.209 --1611 -io ca-- --_ - <br /> Hcrg%t above floor— 101' 264 184 VC _ 10 0a _ <br /> Discanee to highest perfo:-kuens_ 210' 4 0_- }+o0 _12" 10 -Ga <br /> Surface sealed (yrs or {es --'--`r -r_--�, <br /> Crerti r_ckn --- <br /> ' s ii rrr)—.-. —I I <br /> Second ca s-ng depth----- 0-108' ------ <br /> Sccond easing diameter._ 20" - 1/4' -- <br /> Annulzr scat (dr)1b)_--.- -- 103t prolitecl -That 5��7,d_ s?jould-produce u:ore_-;P.tq!r. <br /> G"hecjz_sizing of panp, -dra,;down, <br /> Thickness_ 40 t - r►otor }:orsepower, etc. _ Frotec=_ _ <br /> S � F,- <br /> ( ) Im Q envious S:ratx:Penetrated Depth to _ 0' tion from veY:iculLt <br /> r r-„ffic should <br /> --be provaded_as. soon as possible. __ <br /> (Surface <br /> D -- - - - - - --_ - ----- - — <br /> (9) ater Levels• t <br /> Scatic—_w_-__. <br /> Depth to when purnprre 741 -------- ---- ___ - - - — <br /> �1Q) Pump from acl:son <br /> i 3° t -6Q 03 -- <br /> Lubrication-- __-_�--__.__ -- -- --- -- -- - --- - ------ - - <br /> 1 f}7 IM, Fi A <br /> AuzrLsr) poncr _.._ <br /> Control------­__ <br /> ontrol---- —.---- - 'P-gnsurc <br /> Discharge lacatioa____._._.__._--- <br /> . ---- <br /> sand trap <br /> (11) Frequency of Use-..- -__..-. r <br /> (1 ---- • - - - --- .__.r_�. _.. _.__ ____ <br /> 2) Flood Hazard --- - -----_.�-_ o.c1bl e <br /> (13) Rcm-%rlts and Defcct3___.._.__-_. _ ��� J 09236 <br /> (Use ocher side if necessary) <br /> a <br /> 39-004 (12) <br />