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- <br /> PUBLIC HEALTH SERVICES <br /> I P4VtN <br /> SAN JOAQUIN COUNTY ?:i??•" _ �i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> APPLICATION <br /> FOR <br /> DEPTH OF WELL SEAL <br /> WAVER <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 /> ZZ6o/ N. &'Osa" P-0 �Tir-83o rvz <br /> (sITE ADDRESS) APN N <br /> This <br /> 'Waiver <br /> is rreequested due to the following circumstances: <br /> 1 <br /> This Waiver is a proved based on the following: <br /> Q + <br /> 1 <br /> APPROVED BY <br /> I 'DATE <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 construction deviates from <br /> 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 die following chemicals of <br /> concern: <br /> I, the undersigned owner of the property identified above, hereby request a Waiver from the <br /> minimum well seal depth standards of San Joaquin County based on the information noted <br /> above. I acknowledge that this Waiver information should be disclosed to subsequent <br /> proper WVners. <br /> SIGNATURE Or PR PERTY OWNER . DATE <br /> PRINTim- NAME: k. ta,.1 L1�r, w a leo rn rT �� <br /> MAILING ADDRESS: i 1 '799- N ga\.p+►+• 'CLI . <br /> CITY,STATE,ZIP: T.Jwe lC.6+✓ e A Vim- <br /> FORM:FORM:Eli 03 37 9/3/1999 Well Seal Waivcr.doc <br /> IA Division of San Joaquin County Health Care Services <br />