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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.sigov.org/ehd <br />Depth of Well Seal Waiver <br />Well Permit Number: <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: APN: �d $ -C', 70 <br />City: Le' <br />This Waiver is requested due to the following circumstances: <br />This aivr is ap roved based n the fo wing: <br />Approved by: Date: ob C' <br />Re istered 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. 111;--) , Z7 <br />Signature of Property Owner: <br />Print Name: J �c'✓e CJS U <br />Mailina Address: cmcg.-111 r& <br />Street Address <br />EHD 43-05 <br />4/30/12 <br />City <br />Date: <br />Zip Code <br />DEPTH OF WELL SEAL WAIVER <br />