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SA NJ Oia Q N Environmental Health Department <br /> COUNTY <br /> ,�- Greotne�s ?rows here. <br /> Water Well Permit Waiver <br /> DEPTH OF GROUT SEAL <br /> Well Permit NumberS40C)6K1,30. <br /> This application is made for a waiver of the minimum annular space Well Seal Grout Depth required by San <br /> Joaquin County Well Standards at the following location: <br /> Site Address: e'-J; Z>65Y,17,57 <br /> Street Address City APN <br /> This Waiver is requested due to the following circumstances: - <br /> <-'yr <br /> This Waiver is approved based on the following: <br /> Do <br /> U U <br /> Approved by Date: �D <br /> E D Dir ctor r Aut orized Designee <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 <br /> 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 pIQs sh II be a yzed for the follQWng <br /> chemicals of concern: ,(�� 4 _ �6L2 � UA <br /> �J'U /1u c" Ca <br /> �• cc 1 <br /> I,the undersigned owner of the property identified above, hereby request a Waiver from the minimum <br /> well seal depth standards of San Joaquin County based on the information noted above. I <br /> acknowledge that this Waiver information should be disclosed to subsequent property owners. <br /> p� y t <br /> Signature of Property Owner: �" o' Date <br /> Print Name: <br /> Mailing Address: ,2,3 <br /> Street Address City Zip Code <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />