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SAN ,JOAQUIN COUNTY <br /> 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 Nu be �/i m r: O o �� <br /> This application is made for a waiver of the minimum annular space Well Seal Depth required <br /> by San Joaquin County Well Standards at the following location. <br /> Site Address: `(�l`���, ti f� APN: <br /> City: — <br /> This W igri� requested due t the following circumstances: <br /> This Waiver is approved based on the following: <br /> Approved by: Date: _ <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 Waiver information should be disclosed to <br /> subsequent property owners. <br /> 0 <br /> 1 -7 <br /> Signature of Property Owner I .f ' PCZ Date: <br /> Print Name: a <br /> Mailing Address: <br /> Street Address Gly Zip Code <br /> EHO A3-05 DEPTH Or WELL SEAL WAIVER <br /> 4:30 12 <br />