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,(A Z< SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd Depth Of Well Seal Waiver Well Permit Number: Q V This application is made for a waiver of the minimum annular space Well Seal Depth required by San Joaquin County Well Standards at the following location: Site Address: _/U'�Cr (' APN:_Q City: I cd This Waiver is requested due to the following circumstances: In this region of the Sacramento-San Joaquin Delta acceptable water quality is only encountered at relatively shallow depth,with salinity naturally increasing to deeper groundwater. At this site acceptable water quality was observed in productive zones in the 80- 100 ft interval,with declining groundwater quality encountered below 100 ft depth. Therefore,the well is proposed with a screened interval of 80- 100 ft,with a well seal depth of 60 ft. This Waivr• approvedbased on the following: Approved by: Date: R gistered Environmental Health Specialist The following conditions are placed on the well construction permit and may not be modified: 1. The property owner shall sign this application and acknowledge that the well construction deviates from minimum depth of well seal standards. 2. The annular seal shall terminate in an impervious layer. 3. To verify the water quality from the well, water samples shall be analyzed for the following chemicals of concern: I, the undersigned owner of the property identified above, hereby request a Waiver from the minimum well seal depth standards of San Joaquin County based on the information noted above. I acknowledge that this Waiver information should be disclosed to subsequent property owners.. l Signature of Property Owner:—/ ;( %-C Date: Print Name: ` �I �� Mailing Address:IC 2 ILLY Street Address City Lip Code EHD 43-05 4/30/12 DEPTH OF WELL SEAL WAIVER