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faUG-31-2016 16:30 From: To:2099311243 Paae:1"1 <br /> �= <br /> �.. s. 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.sigov.org/ehd <br /> Depth of Wel! Seal Waiver <br /> Well Permit Number: O 7 5 y <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: /'6510 I,J- 13,kQ -15L," 2p, APN: /29-2oo--[S` <br /> City: a <br /> This Waiver is requested due to the jfollowing circumststan_ces: <br /> : <br /> This Waiver is approved based on the following: <br /> O A I o le A L- <br /> "al <br /> Approved by: --n_ 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 Walver 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 /> Signature of Properlyowner: <br /> Print Name: _ L <br /> � <br /> Mailing Address: WAV- i <br /> Street Address city Zip Code <br /> EHO 49-OS <br /> 4130112 DEPTH OF WELL SEAL WAIVER <br />