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C . , <br /> �• far �,�?/ � � _I r, <br /> INFORMATION:GEOGRAPHICAL <br /> MONITORINGOTHER <br /> INSTALLATION: 0 WELL SYSTEM REPAIR CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL* <br /> TYPE OF :ACEWOGE07kEPHM�A <br /> DEPTH <br /> 0 SOIL BORING <br /> . . <br /> INTENDEDC •.SPECIFICATION <br /> . CONDUCTOR <br /> •DOMES71C PRIVATE ■ PACK/SfZE,___ WELL CASING TYPE— WELL CASING DIA_ <br /> ■ IRRIGATION/AG <br /> •MONITORING GROUT SEAL PUMPED: 0 YES Q NO <br /> ■ CHRISTY BOX ■ STOVE PIPE CONCRETE . .• : ■ . NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUC7nON/DRILLlNG METHOD: MUD ROTARY—AIR ROTARY—AUGER—CABLE— OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION <br /> : 1 • • 1 • ' INSPECTIONS <br /> SIGNEE� _' / ..�:��'� = T �� , _iii • <br /> i►'�i�iiT■iiiiiiiii��iiii■li�iiiiiiiiiiiiiiii . <br /> fill■liilllllllllt:�iiiiGiiiiiiiiiiiiiiiii <br /> lillllllllll�3lii ii1/ilii■li illlllllllliilli <br /> ill llllllNllilHilli ll illllilllt3��171:�i 111 <br /> illHlllH ll `�'I�,r1J��'t�y�iiltCJll lllll7!■llllii <br /> Nllll ���il�llllllliii lC■1■lZWI■ii <br /> ,ii DEPARIMENrUSEONLY <br /> ,. 1I , . Arm <br /> .Da <br /> DN%tructim Inspwfim By Dat <br /> ;, AMOUNT rCHECK#�/,ffTMTkTT&2 PERMIT/SERVICE REQUEST# <br />