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SAN J OA Q U I N Environmental Health Department <br />ti. COUNTY <br />Asa-; ,T'` Greotne_s groves here. <br />Water Well Permit Waiver <br />DEPTH OF GROUT SEAL r/ <br />Well Permit Number.��d6� K1 30- <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: J <br />Site Address: e�,J:.Z>G%Z-%7-% �,e!ZCleE %�/%C "z 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: n <br />Approved byQ)Date: <br />E D Dir ctor dr Aut orized Designee <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/y� pl s shj� II be a yzed for the foll ng <br />chemicals of concern: �,,P_ . �; (�7� i. `Tu L� fir( <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: �` e"' Date / `z <br />Print Name: <br />Mailing Address: <br />Street Address <br />city <br />Zip Code <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />