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z SAN JOAQUIN COUNTY <br /> i.; S'•! ENVIRONMENTAL HEALTH DEPARTMENT <br /> '�•' . :f 1$$6 fast Hazelton:Avenue,-Stockton, GA-85205-623 :..._., -- ;- -- <br /> - <br /> Tefephona.(209)486-342p Fax.(209)464-0138 Web.www.sjg6v.org/ehd <br /> Depffi of Well Seal Waiver <br /> Well Permit Number. /J?� <br /> This application is.Trade for a waiver of the minimum annular space Well Sean Depth required <br /> by San Joaquin County.Wol Standards at the following location, <br /> SiteAildress:( � s ;c_ ,/A / /7�/� RN:._ <br /> city: o <br /> This Waiver is te*quested due to;�ollowing circumstances: <br /> This Waiver is approved based on the.following: <br /> Approved by: Date: <br /> Registered Environmental Health Specialist <br /> The following conditions are placed on the well construction permit and may tint be_-m-9dified: <br /> f. 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 concam: <br /> I, the undersigned owner of the property identitled 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 properly owners. h <br /> Signature of Proper. Cwner� <br /> Print Name: <br /> Mailing Address: ;� Z . <br /> Street Address city zip cede <br /> EHO 43-05 DEPTH OF WELL SEAL WAIVER <br />