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TYPE OF WORK (Check) :e-�NEW WELL / / DEEPEN / / RE9AIDITION /_/ DESTRUCTION /- <br /> PUMP INST LATION / / PUMP 1�lAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES JDQPIT PRIVY <br /> SEWAGE DISPOSAL FIELD _f CESSPOOL/SEE AGE PIT OTHI <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL tl� PUBLIC DOMESTIC WE <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT] <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S—D N <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: (' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.I <br /> ?UMP REPLACEMENT: / / State Work Done <br /> ?UMP .REPAIR: / / State Work Done <br /> )ES•TRUCTION OF WELL: Well Diameter Approximate Del <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Hes <br /> and the State of California pertaining to or regulating well construction. Within <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Hes <br /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. 7 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROU <br /> _ RIOR TO GRO G AN A F N INSPECTION. <br /> iIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMEN USE ONLY <br /> ?RASE I <br /> TPLICATION ACCEPTED BY �- ATE 3 <br /> 1DDITIONAL COMMENTS : <br /> PHASE II ROUT INSPECTION PRASFOIU/FINAL INSPF <br /> INSPECTION BY DATE - 7-7!7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />