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I I I <br /> I' - <br /> • -�/ _ia�`_ ,�':��l��I=...• ._rte � R�_ /� �. � <br /> 1• <br /> CONTRA <br /> •'l•, <br /> Xp DA <br /> GEOGRAPHICAL I1 ' 1N: COORDINATES TOWNSHIP— — SECTION <br /> MONITORING <br /> INSTALLATION: . WELL SYSTEM REPAIR . CROSS-CONNECT REPAIR . VAPOR EXTRACTION <br /> TYPE OF PUMP: . REPAIR H.P. . DFPTHPUMP SET FIRST <br /> • . . GEOITCHNICAL# . SOIL BORING . DESTRUCTION:— <br /> INTENDED <br /> \. 1 1 TYPE OF WELL CONSTRUCTION ( 1. <br /> 0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA_ CONDUCTOR CASING DIA_ <br /> ■ DOMESTIC PRIVATE ■ GRAVEL PACK/SIZE_ WELL CASING TYPE— WELL CASING DIA_ <br /> IRRIGATION/AG• <br /> •MONITORING GROUT SEAL PUMPED: 0 YES CI NO <br /> 13 CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES 0 NO <br /> APPROXIMATE WDEPTH <br /> HEREBYPROPOSED CONSTRUCTION/DRILI.JNO METHOD: MUD ROTARY—AIR ROTARY—AUGER—CABLE— OTHER <br /> I 1 1 1 '1 1 ' I 11 IACCORDANCE <br /> 1 / 1 . ORDINANCES, 1 1 1 1 1 ' <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORNMAN'S <br /> COMPENSATION <br /> UNI 24 •OUR ADVANCE . O' INSPECTIONS <br /> SIGNEDOML _.TmXjWA4A_i�&�4L__,ATE6a2&L_ <br /> !!!!!!!!!rilnl��cnli►•n!!!!!!!!!!llrrnw.nrlwm�!■■n!!! <br /> MMM <br /> 1RTMENT USE ONLY <br /> Application Accepted Byr R <br /> Gmut Inspection By Date--Pump <br /> Destruction Inspection By Date <br /> •1• 1 AMOUNT <br /> REMITTED ��� • 1 • I, <br />