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r SAN J OA Q U I N Environmental Health Department <br /> —COUNTY— <br /> Greatness <br /> OUNTYGreatness grows here. <br /> Water Well Permit Waiver <br /> DEPTH OF GROUT SEAL <br /> Well Permit Number <br /> This application is made for a waiver of the minimum annular space Well Seal Grout Depth required by San <br /> Joaquin County Wellta{'n�d(arrd(s at the followin lo�ca)tiom <br /> Site Address: 1 V I v '�� jrA�A <br /> Street Address City U APN <br /> This Waiver is requested due to the following circumstances: <br /> This W v r is approved based on the following: / <br /> 1 <br /> '2,J° 7 , <br /> Approved by — iy Date: (7 <br /> EHD' irector or Authorized 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 samples shall be analyzed for the following <br /> chemicals of concern: <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 /> Signature of Property Owner: !'G Date 2 <br /> Print Name: <br /> Mailing Address: 2 7 <br /> Streef Addre s 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 />