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n-tiiiU1M - <br />14 SAN JOAQUIN COUNTY <br />�IS 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 annu!ar space Well Seal Depth required <br />by San Joaquin County Well Standards at the following location: <br />Site Address: APN: /� 7/ <br />City: G <br />This Waiver is re,quested due to the following circumstances <br />gistered 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 />1, 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 W ' er information should be disclosed to <br />subsequent property owners. /= <br />Signature of Props y OVviicr: <br />Print Name: <br />Date: OCoL <br />Mailing Address:0, �oX 9 XVA-D�n/ %S a3.6 <br />Street Address City Zip Code <br />EHD DEPTH OF WELL SEAL WAIVER <br />-05 <br />Cl30/12 12 <br />