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UC HE <br /> ALTH SERVI <br /> -�P-U- B <br /> CES <br /> SAN JOAQDIN COUNTY a ; <br /> 'ENVIRONMENTAL HEALTH DIVISION <br /> Kr�a�i�en Furst,SM.D. MH., Healfih Officer <br /> 1►..l.Lta i .P. Gtr'lFO R�1P I <br /> 3o4 East Wcbbex Avenue,Third Floor * Stockton, CA 95202 <br /> 209/468-5420 <br /> APPLICATION <br /> FOR <br /> WArVER ON 200 FOOT <br /> WELL SEAL <br /> This is an applicationfor a waivez to the 200 foot minimum annular seal for a domestic well <br /> in a contaminated arca. This request is being made due to factors which may include,but <br /> not limited to,water quality andlor Salt water degmdation or intrusion. The following <br /> conditions are placed on the permit and may not be modified: <br /> I. The property owner shall sign this application. <br /> 2. The annular seal shall be as deep as possible. <br /> 3- The annular seal shall terminate in a non-pervious layer. <br /> 4. The well,immediately after construction shall be tested for the chemicals checked_ _ <br /> below, <br /> Nitrate lee <br /> Vinic _ Gt <br /> DBCP - -�- <br /> 2L_Other Chl�orofo <br /> The propmly owner hereby recognizes that the State and County minimum standards are set <br /> to provide the highest quality water and to protect that wager,and that in requesting a waiver <br /> from that standard,the County of.San Joaquin cannot assure that the water quality of <br /> r shallow aquifers will meet drinking water standards and in fact may not. Therefore,the <br /> above required chemical tests are only a minimum for identifyinghealth concerns, <br /> additional testing by the property owner is recommended by this Department to assure safe <br /> drinldng water. <br /> a <br /> w <br /> Sig&ttue of Property owner . _ Date <br /> printed name <br /> ( Post-it®Fax Note 7871 Date 0 pae@S, __ __� �yLr.�rfv4 S c• " <br /> From DZ 20unty Health Cate Services r-�n <br /> CoMept. Co. <br /> I Phone# P o <br /> C <br /> on InrPeeflon 8 � ��"��•• ""A'^•vxnun ey <br />