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<, x, SAN JOAOUIN COUNTY <br /> y ,M, <br /> ;,. i ENVIRONMENTAL HEALTH DEPARTMENT <br /> r a 'iL <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> Depth of Well Seal Waiver <br /> Well Permit Number: <br /> This application is made for a waiver of the minimum annular space Well Seal Depth required <br /> by San Joaquin County Well Standards atthefollowing location: i <br /> Site Address: I W 1`U � `` 7 VJ APN: <br /> City: Z <br /> This gWaiver is requested due to the following circumstances: <br /> U C01 IL o )er 1,j I <br /> This Waiver is approved based on the following: <br /> GraC <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. �j <br /> Signature of Property Owner:: Date: <br /> Print Name: ( ` <br /> Mailing Address: WKV�1vN , 2• Wn <br /> Street Address City Zip Code <br /> EHD 43-05 DEPTH OF WELL SEAL WAIVER <br /> 4/30/12 <br />