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SAN JOAQUIN COUNTY <br /> < ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 E Main Street Stockton,CA 95202-3029 <br /> (209)468-3420 Fax:(209)464-0138 fYcb:www.co.san-joaquinxa.us/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 by <br /> San Joaquin County Well Standards at the following location: <br /> Site Address: APN: l D(o G p <br /> City: <br /> This Wtaiver�siuested d�'�to a following circumstances: f <br /> This Waiver i approved based on tt a following: i + <br /> Approved by: I �� Date: <br /> RegiEnvironmental 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 Property Owner. Date: <br /> Print Name: X1;42— <br /> Mailing <br /> Z Mailing Address: S'`'am N tnl21r L4viA 14tH 953 y <br /> Sa,.L nd&— city zip Coda <br /> Ikph o(Pkn SeA Wsi'w <br /> EI{D I3Q:td5 <br />