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SAN JUA11UI ' l — ?V!1*01Mitent-?l Health Dap ;'...''—ill <br /> i-' v <br /> Water Well Permit Waiver <br /> DEPTH OF GROUT SEAL <br /> Well Permit Number <br /> I his 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: . _ 1.131 W Bowman Road French Camp.__CA 95231 <br /> Street Address City APill <br /> This Waiver is requested due to the following circuMstances: <br /> This area has high water level and salt -rater issue in wells over 80' <br /> We have done 20' cement seals Previously for these reasons. _ <br /> This lWaiver is approved based on the following: <br /> L je i) Skc,iI coitr, R)z b.fo}�? Ql� S�o1JP �Jr1fP./ vJe �� <br /> Lei r 6611rcis <br /> Approved by , �� Z-Z— - -- Date: d <br /> DID Director or Authorized Des:gn-3e <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. -Tine 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 /> cher;cats of concern: c r►erg l mrnr'rdjl f tf Cob rt,.,,,- <br /> 1, <br /> t,.,,,I,the undersigned owner of the property identified above.. hereby request a Waiver from the minimum <br /> well seat depth standards of San Joaquin County based on the information noted above. <br /> acknowledge that this Waiver information should be disclosed to subsequent property owners. <br /> Signature of Prop?rty Owner: � ��� ( Date <br /> Print Name: <br /> Mailino Address fj <br /> ,Street Address City Zip Code <br /> 1868 F. Hazelton avenue I Stockton, California 952051 i 209 4'a8-3-"•201 F 209-64-0138 :�::v.sjgov.org/ehd <br />