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l�q.��.cam•. <br /> ,i�. -` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> te;�4aN� Telephone:(209) 468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> Depth of Well Seal Waiver <br /> Well Permit Number: <br /> This application is made for a waiver of the minimum annu!ar space Well Seal Depth required <br /> by San Joaquin County Well Standards at the following location: <br /> Site Address: 1'-V� /dam % APN: /'2 7/ D <br /> City: 7-0e--A Y7d-I <br /> This Waiver is reguested due to the following circumstances <br /> oThisWaive 4iisapproveclg4asedon�hef IlowinT <br /> Approved by: Date: <br /> R gistered Environmental Health Specialist <br /> The following conditions are placed on the well construction permit and may not be modified.- <br /> 1. <br /> odified: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 /> 1, 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 thi W ' er information should be disclosed to <br /> subsequent property owners. <br /> Siggnaturc Of P1op- OliJncr: C + �QC <br /> alc. <br /> Print Name: iVr <br /> Mailing Address: 0, 8 ox 3.6 <br /> Street Address City Zip Code <br /> EHD DEPTH OF WELL SEAL WAIVER <br /> Cl30/12 12 <br />