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"label": "driven", "pdf_field_name": "topmostSubform[0].Page1[0].driven[0]", "pdf_field_type": "CheckBox", "reading_order": 42 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 496.68, "t": 476.88, "r": 507.72, "b": 465.84 }, "text": "bored", "field_kind": "checkbox", "label": "bored", "pdf_field_name": "topmostSubform[0].Page1[0].bored[0]", "pdf_field_type": "CheckBox", "reading_order": 43 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 130.56, "t": 464.28, "r": 189.12, "b": 446.52 }, "text": "Depth of Casing", "field_kind": "text", "label": "Depth of Casing", "pdf_field_name": "topmostSubform[0].Page1[0].Depth_of_Casing[0]", "pdf_field_type": "Text", "reading_order": 44 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 370.68, "t": 463.8, "r": 381.72, "b": 452.76 }, "text": "dug", "field_kind": "checkbox", "label": "dug", "pdf_field_name": "topmostSubform[0].Page1[0].dug[0]", "pdf_field_type": "CheckBox", "reading_order": 45 }, { "page": 1, "type": 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"topmostSubform[0].Page1[0]._1[0]", "pdf_field_type": "Text", "reading_order": 49 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 42.36, "t": 408.6, "r": 562.8, "b": 390.84 }, "text": "[2]", "field_kind": "text", "label": "[2]", "pdf_field_name": "topmostSubform[0].Page1[0]._2[0]", "pdf_field_type": "Text", "reading_order": 50 }, { "page": 1, "type": "TEXT", "location": { "l": 41.28, "t": 379.92, "r": 565.92, "b": 334.08 }, "text": "Any work that will be claimed under the Iowa Department of Public Health Grants-to-Counties Well Program grant must be approved by the local County Agent before any work is performed on the well.", "reading_order": 51 }, { "page": 1, "type": "TEXT", "location": { "l": 43.2, "t": 331.44, "r": 561.6, "b": 307.44 }, "text": "This well will be submitted for cost share assistance payment under the Grants-to-Counties Well Program.\n□ Yes □ No", "reading_order": 52 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 265.2, "t": 317.4, "r": 276.24, "b": 306.36 }, "text": "This well will be submitted for cost share assistance payment under the Grants-to-Counties Well Program", "field_kind": "radio", "label": "This well will be submitted for cost share assistance payment under the Grants-to-Counties Well Program", "pdf_field_name": "topmostSubform[0].Page1[0].This_well_will_be_submitted_for_cost_share_assistance_payment_under_the_GrantstoCounties_Well_Program[0]", "pdf_field_type": "RadioButton", "value": "Off", "reading_order": 53 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 311.28, "t": 317.4, "r": 322.32, "b": 306.36 }, "text": "This well will be submitted for cost share assistance payment under the Grants-to-Counties Well Program", "field_kind": "radio", "label": "This well will be submitted for cost share assistance payment under the Grants-to-Counties Well Program", "pdf_field_name": 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reconstructed this well in a manner defined by Iowa Administrative Code 567.49.10.", "reading_order": 58 }, { "page": 1, "type": "TEXT", "location": { "l": 130.56, "t": 185.28, "r": 258.24, "b": 170.88 }, "text": "Signature of Contractor", "reading_order": 59 }, { "page": 1, "type": "TEXT", "location": { "l": 130.08, "t": 185.04, "r": 506.64, "b": 171.6 }, "text": "_____ _____", "reading_order": 60 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 400.68, "t": 202.68, "r": 562.8, "b": 184.92 }, "text": "Cert. No", "field_kind": "text", "label": "Cert. No", "pdf_field_name": "topmostSubform[0].Page1[0].Cert_No[0]", "pdf_field_type": "Text", "reading_order": 61 }, { "page": 1, "type": "TEXT", "location": { "l": 456.48, "t": 185.04, "r": 505.92, "b": 171.6 }, "text": "Cert. No.", "reading_order": 62 }, { "page": 1, "type": "TEXT", "location": { "l": 42.72, "t": 155.28, "r": 148.8, "b": 145.2 }, "text": "
\"Image\"
\n", "reading_order": 63 }, { "page": 1, "type": "TEXT", "location": { "l": 66.72, "t": 145.2, "r": 522.96, "b": 132.72 }, "text": "Or Well Owner Date Renovated", "reading_order": 64 }, { "page": 1, "type": "TEXT", "location": { "l": 438.72, "t": 146.16, "r": 525.36, "b": 133.2 }, "text": "Date Renovated", "reading_order": 65 }, { "page": 1, "type": "TEXT", "location": { "l": 77.52, "t": 128.4, "r": 529.2, "b": 114 }, "text": "Complete one form for each well and submit within 30 days to the local county agent", "reading_order": 66 }, { "page": 1, "type": "TEXT", "location": { "l": 34.56, "t": 109.92, "r": 429.36, "b": 95.28 }, "text": "☐ Yes ☐ No This well qualifies for Grants-to-Counties grant payment", "reading_order": 67 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 36.72, "t": 108.36, "r": 47.76, "b": 97.32 }, "text": "This well qualifies for Grants-to-Counties grant payment", "field_kind": "radio", "label": "This well qualifies for Grants-to-Counties grant payment", "pdf_field_name": "topmostSubform[0].Page1[0].This_well_qualifies_for_GrantstoCounties_grant_payment[0]", "pdf_field_type": "RadioButton", "value": "Off", "reading_order": 68 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 84.72, "t": 108.36, "r": 95.76, "b": 97.32 }, "text": "This well qualifies for Grants-to-Counties grant payment", "field_kind": "radio", "label": "This well qualifies for Grants-to-Counties grant payment", "pdf_field_name": "topmostSubform[0].Page1[0].This_well_qualifies_for_GrantstoCounties_grant_payment[0]", "pdf_field_type": "RadioButton", "value": "Off", "reading_order": 69 }, { "page": 1, "type": "TEXT", "location": { "l": 34.32, "t": 91.68, "r": 438, "b": 76.32 }, "text": "Amount eligible for Grants-to-Counties payment: $ ___", "reading_order": 70 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 310.56, "t": 96.24, "r": 436.8, "b": 78.48 }, "text": "Amount eligible for Grants-to-Counties payment", "field_kind": "text", "label": "Amount eligible for Grants-to-Counties payment", "pdf_field_name": "topmostSubform[0].Page1[0].Amount_eligible_for_GrantstoCounties_payment[0]", "pdf_field_type": "Text", "reading_order": 71 } ] } ]