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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/chd <br />Depth of Well Seal Waiver <br />Well Permit Number: yAcV F1, -?�-( <br />This application is made for a waiver of the minimum annular space Well Seal Depth required by <br />San Joaquin County Well Standards at the following location: <br />Site Address: 1187 E Fisk Road <br />City: French Cam <br />APN: 17707038 <br />This Waiver is requested due to the following circumstances: <br />The water below 200 feet has an oder and is poorer <br />quaility - we request a 150'± seal based on the nearest <br />clay formation. <br />This Waiver is approved based n the following: <br />Approved by: <br />Registered Environmental Health Specialist <br />Date: 1 42 3 �0 �, <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 <br />construction deviates from minimum depth of well seal standards. <br />2. The annular seal shall terminate in an impervious layer. <br />IN <br />3. To verify the water quality from the well, water samples shall be analyzed for the <br />following chemicals of concern: /✓ c �� i - <br />X4,(( L -;1 r1( a-o.n(cJ7y� a <br />/ccS cz�f 4. l2 IX�GI G'•tu CC ZL `%�v? l..•,y.l� (cam/ telt'[( .2. �p ...t}� <br />I, }he undersig2ed ower of the propeiiy identified above, hereby request a Waiver from <br />the minimum well seal depth standards of San Joaquin County based on the information <br />noted above. I acknowledge that this Waiver information should be disclosed to •K� �_�-'L <br />subsequent property owners.T Signature of - ? <br />gn Property Owner: Date: <br />Print Name: <br />Mailing Address:l <br />Sawt Address City Zip Code <br />END 43-02-003 <br />6/19/2003 Depth of Wdl Seal Waiver <br />