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elm :6 <br /> 1 <br /> Lit• <br /> • I r <br /> GEOGRAPHICAL1 ' IN: COORDINATES X Y TOWNSHIPSECTION <br /> INSTALLATION:TYPE OF WELL: 0 NEW WELL [I REPLACEMENT WELL 0 MONITORING WELL 0 OTHER <br /> ■ WELL SYSTEM REPAIR ■ CROSS-CONNECT REPAIR ■ VAPOR EXTRACTION <br /> TYPE a <br /> 1 ■ NEW WREPAIR H.P. / r �Irr� • <br /> ■ • • ■ GEOTECHNICAL# ■ SOIL BORING ■ 1 • <br /> INTENDED OF WELL CONSTRUCTIONSPECIFICATION <br /> 0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ■ 1• WELLCASINGDIA <br /> ■ ■ DRIVEN • DEPTH SPECIFICATION <br /> ■ • OTHER GROUT /NAME <br /> 0 MONITORING GROUT SEAL PUMPED: 0 YES 0 NO <br /> ■ :• ■ • • 1 1' ■ ■ • <br /> APPROXIMATEDEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METH•1 1 '• '• OTHER- <br /> I <br /> PREPARED THIS APPLICATION1 THAT THE WORKDONE IN ACCORDANCE <br /> JOAQUIN1 /1 ' 1IANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUINCOUNTY. <br /> /►i <br /> TITLE: � DATE: it <br /> ii�iiiiiii�■iiii�iiiiw�i��iiiiiiiii���iiii` <br /> Application • 1 -Date <br /> Grout Inspection By •. . . . Vit ' / Date <br /> Destruction InspectionDate <br /> �� ��.� <br />