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Mailing Address: /."-' •''l <br />-) City Street Address Zip Code <br />SAN JOAQUIN <br /> <br />..7:nvironmental Health Deparinmnt <br />i_J Y- <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 Well Standards at the following location: <br />Site Address: 1131 W Bowman Road French Camp, CA 95231 <br />Street Address City APN <br />This Waiver is requested due to the following circumstances: <br />This area has high water level and salt water issue in wells over 80' <br />We have done 20' cement seals previously for these reasons. <br />This Waiver is approved based on the following: <br />Onfer- II Kkcliieoirpiy 1441? etil Slott "'4" 149 1/ <br />Approved by Z-Z- Date: !AO 01.0 <br /> <br />EI-ID Director or Authorized Desrgnee <br /> <br />The following conditions are placed on the well construction permit and may not be modified: <br />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 />To verify the water quality from, the well, water samples shall be analyzed for the following , <br />chemicals of concern. vroef41 f10-(o/i te.:,1e) otbi-0ci1 broproixre J <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 />_ <br />Signature of Property Owner: Date <br />^* <br />Print Name: <br />, <br />1865 F. Hazelton Avenue I Stockton, California 95205 I T 209 458-3420 1 F 209 464-0138 I v.A...,w.sigov.ora/end