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RUG-31-2016 16:30 From: To:2099311243 Pase:1�1 <br /> �aN'tY <br /> .rte'Ab <br /> y. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 18613 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> relephone:(209)468-3420 Fax:(209)464.0138 Web:� www.sigov.org/ehd <br /> Depth of Well Seal Waiver <br /> Well Permit Number. _�X c 6 7 y S 3y <br /> This application is made for a waiver of the minimum annular space Well Seal Depth required <br /> by San Joaquin County Well Standards at the following location: <br /> Site Address:A 510 W. BA '.J ISL-W1> IZV APN: <br /> city: o <br /> This Waiver is requested due to the following circumstances: <br /> h rah �S a + eC>N .rn,•��0 i <br /> 1 <br /> This Waiver is approved based on the following: <br /> P Tton, tjxAl / <br /> Approved by: Date: <br /> Registered Environmental Health Specialist <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 /> 3. To verify the water quality from the well, water samples shall be analyzed for the <br /> following chemicals of concern: <br /> I, the undersigned owner of the property 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 <br /> subsequent property owners. <br /> Signature of Propeiiy WneC � Date: <br /> Print Name: <br /> Mailing Address: 98 Sl C_ <br /> Street Address City Epp Code <br /> EHE4905 OEPT OF WELL SEAL WAIVER <br /> 4130112 <br />