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d <br /> caw SAN.JOAQUIN COUNTY <br /> IQAUII>� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> � Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> Depth of Well Seal Waiver <br /> Well Permit Number: <br /> This application is made for a waiver of the minimum annular space Well Seal Depth required <br /> by San Joaquin County, M <br /> WellStandardsat the following location: <br /> Site Address: -37✓ I[t P- 4 APN: <br /> City: G '1 <br /> GC(/ SZOV <br /> This Waiver is requested due to the following circumstances: <br /> 20' QLMR WAI IS S r <br /> — LOMPAS AS qood Of NalitU. <br /> This Waive epgved base on the following: <br /> isaf= <br /> 74f isv <br /> Approved by: Date: / Y <br /> Registered Environmental Health Specialist <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 <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 /> I,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 this Iver information should be disclosed to <br /> subsequent property owners. <br /> Signature of jPg-oWrty Owner: - Date: <br /> Print Name: iJ V y /tl""U��1-S S i CJ <br /> Mailing Address: -5Y,('0 r LZZ E C S/oGKTo 9.S <br /> A) "Zoi�, <br /> Street Address City Zip Code <br /> wt <br /> EHD 43-05 DEPTH OF WELL SEAL WAIVER <br /> 4/30/12 <br />