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SAN JOAQUIN COUNV"N <br /> < ENVIRONMENTAL HEALTH DrPARTMENT <br /> 600 E Main Street Stockton.CA 95202-3029 <br /> N (209)468-3420 Fax:(209)464-0138 Web:www.co.san-joaquin.ca.us1ehd <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 by <br /> San Joaquin County Well Standards at the following location: (� <br /> Site Address: <br /> L1 l•� ilk vM,� -1n�G k2 Z` APN: � <br /> City: S n JA:= <br /> This Waiveris Fqrjested du to thp fo owing ci umstances: /1 1 <br /> 71) <br /> This Waiver approved ed on th following: <br /> ---- Approved by: Date: z t <br /> 4, isteregd 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 concem <br /> 1,the andersigned 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. 1 acknowledge that this Waiver information should be disclosed to <br /> subsequent property owners. <br /> Signature of Property Owner: a Date: `3 <br /> Print Name: 1411-111 Z) <br /> Mailing Address:' S`'-r3 N W(2�r iG v� L4utr15 S�uiO 9533 y <br /> succi Adam city zip CDae <br /> Depc6 a(x•A Sal w:R <br /> E11D 3QSA'c <br /> �Z�l� <br />