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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue, Third Floor • Stockton, CA 95202 <br /> 2091468-3420 <br /> APPLICATION <br /> FOR <br /> DEPTH OF WELL SEAL <br /> WAIVER <br /> WELL PERMIT NUMBER: <br /> This application is made for a Waiver of the minimum annular space WELL SEAL DEPTH required by <br /> San Joaq�n County Well St (J&-ds at the following location: <br /> ' T� _ <br /> (SITE ADDRESS) APN 4 <br /> This Waiver is requested due to the following circumstances: <br /> r' �.- is w�.►ase_- kl , *4-e- <br /> h This Waiver is approved based on the following: <br /> APPROVED BY: /�- <br /> DATE <br /> The following conditions are placed on the well construction pera tit and may not be modified: <br /> 1. The property owner shall sig•i this application and acknowledge that the well construction deviates from <br /> minimum depth of well sea)standards. <br /> 2. The annular seal shall teratinate in an impervious layer. <br /> 3. To verify the water quality from the well, water samples shall be analyzed for the following chemicals of <br /> concern: r <br /> I, the undersigned owner of the property identified above, hereby request a Waiver from the <br /> minimum well seal depth standar of San Joaquin County based on the information noted <br /> above. I acknowledge th �aiver information should be disclosed to subsequent <br /> property owners. <br /> —>SIGNATURE DF PROPERTY OWNER DATE <br /> PRINTED NAME: ��4.e✓' D <br /> MAILING ADDRESS: 7 q7 W ' <br /> CITY,STATE,ZIP: { � <br /> FORM:EH 03 37 9/3/1999 Well Seal Waiver.doc <br /> A Division of San Joaquin County Health Care Services <br />