Laserfiche WebLink
SAN JOAQUIN <br />'� COUNTY <br />i <br />;opFtta�� Greotn . gru N/. here, <br />Environmental Health Department <br />Water Well Permit Waiver <br />DEPTH OF GROUT SEAL <br />Well Permit Number,4y <br />This application is made for a waiver of the minimum annular space Well Seal Grout Depth required by San <br />Joaquin County Well Standards at the following location: <br />Site Address: j� '/ 17? Z�� �G%�Z7% ��'/ Cec� ��/%C <br />Street Address City APN <br />This Waiver is requested due to the following circumstances: <br />This Waiver is approved based on the following: <br />Approved by <br />Di <br />rized Designee <br />Date: � <br />The following conditions are placed on the well construction permit and may not be modified: <br />1. The property owner shall sign this application and acknowledge that the well construction deviates <br />from minimum depth of well seal standards. <br />2. The annular seal shall terminate in an impervious layer. <br />3. To verify the water quality from the well, water mpl s sh II be ^a� lyzed for the foil ng <br />chemicals of concern: .�e_� GLI) �Tu �v I <br />I, the undersigned owner of the property identified above, hereby request a Waiver from the minimum <br />well seal depth standards of San Joaquin County based on the information noted above. <br />acknowledge that this Waiver information should be disclosed to subsequent property owners. <br />Signature of Property Owner: Date /2,e,z 26;1 <br />Print Name: Ap/l/J7x� <br />Mailing Address: <br />Street Address City Zip Code <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 � www.sjgov.org/ehd <br />