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TYPE OF WORK (Check)+, NEW WELL 171r DEEPEN /7 RVAONDITION /7 DESTRUCTION ? <br /> PUMP INSTALLATION / / PUMP _.;PAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEARL T, SEPfiIC.,„TANK/oyaJ SEWER LINES/ ja-, PIT PRIVY <br /> ^SEWAkdE� 6ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT <br /> _ PROPERTY EINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA'. <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 <br /> Cathodic Protection Rotary Type of Grout C b atc n <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of-Pump H. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPI.REPAIR: /% State Work Done <br /> DESTRUCTION OF WELL: Well Diameter lQ 'a .• - Approximate De <br /> Describe Ma terial -an/dr-Procedure / <br /> All -14 <br /> I hereby agree to comply -with all laws and 'regulations of the lin Joaquin Local He <br /> and the State of California pextafnfng-tor-pt regulating well construction. Within <br /> after completion of my work on a new well, I will Furnish the San Joaquin Local He <br /> _ WELL DRILLERS REPORT of the well and notify them"befozie putting the well in use. <br /> information is true to the best of my kno*-jedge and belief. I WILL CALL FOR A GRO <br /> PRIOR TO GROUTING AND 'A'FINAL INSPECTION. - ' <br /> SIGNED ff- " TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 91 �t� DATE <br /> ADDITIONAL COMMENTS: 42 11 <br /> PHASE II GROUT INSPECTION PHASE III INAL INSP <br /> INSPECTION BY DATE 7—Lg 7,7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />