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-: 25I 56 08:58a p.2 <br />: Vl 4.Jf/VUO 11.70 404'.,I zO C14V 1RrJ1Yf'1_I41/-� 1'I �F+L I-. "4..'1L' J <br />SAN JOAQUIN COUNTV <br />Em7RONNIEN rAL HEALTH U1PAP Tm-r <br />304 Fast Webcs Avenue, r Floor, Stoektm CA 95202 <br />(209) 468-3420 P (209) 464-0138 Web: www.ec.3an-jO2gUi--&C2.ns/ehd <br />D,�th of Well Seal Wa ar <br />Wei ft; -mit Number- 1� r6e() YT(, I I <br />This awicatiora it rack for a v� aiv- of the minimum antmlar space W:a S eal Dz�-th rcquiird by. <br />Sm Joaq, .' :1 Goer N Wei' &Y�mdare3 at the following locroor, : <br />SItAd.Irmz: 197 - r>:, Road —PN: 1770'70.>8 <br />W, in W a ver is raqur tr4 due t2� nirz :oltowing circumstances.: <br />• ^ �'• a 1s .�s�.i=�i,_i:�;.:.�k'.�%. a_..;..�..e " ,'lL'.rS an oder � �L.�.t.+�r--Fs+i.:2�.E.T:._._ _ <br />�,nFCIc%— 1_Ljl we reggeszt a 150'± seal based ci7 Oe nearest: <br />This Waiver is arprove', I.msee ars ;,1,e Following: <br />A_pprQJed jay: �"_ `_�1/�^ -� De' tc: <br />Regi: Smir wnental Health SpeeiZ: , <br />The f9i?.C'F'.T% zo;i ". ! ons ar-piazad on the Well construction p -ti- iit and may rot b-- ii,odi ed: <br />Ta ov.-.:.e� S�zall sign this Replication ff. d. <br />corse- ucu�in Se i ates ftvm minimum depth o- well sm I staind ds. <br />2. 7h- annotz seer X41't trrmhwe in an impearviou'; iayer. <br />3. : g - <br />,jFGj Yy trap w ee . ,a z&Tity from the well, waster ; ,pl�:3 i 1 be F,,glyzed for the <br />fOh;c ivl _,g chap* ra :says `�f cone m: <br />i(f rJ !,! �•c F ^f p. ��. rr �_ ll `C. fr..- ,_ <br />141, <br />r k L n a^s D r _S a a t/ {f [t tir 2 L <br />I, the underst�ed 4.�_ter o! xa rrnpei� identified nbo've; hoxYby request a Waiver from B_ <br />the adbi um well Read depth standards of San Joaquin Couoth' butd or, 6� iuf-armaaiied <br />toted ab , 7 i .n pvriedgc flat ehia Waiver informatt <br />subsCgdTe3 <br />Sipature Of Property Own= <br />Print Name: �� � E ' J - %'� L �ss•.s <br />Mai6i7g Address: <br />Scxs Add-" Cry 712 cet <br />RMD 0.4140 <br />