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P' <br />R < <br />4��Fo•RCi <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street <br />Stockton, California 95202-3029 <br />Well Permit Number: <br />Website: www.sjgov.org/ehd <br />Phone: (209) 468-3420 <br />Fax: (209) 464-0138 <br />Waiver <br />DIRECTOR <br />Donna Heran, REHS <br />ASSISTANT DIRECTOR <br />Laurie Cotulla. REHS <br />PROGRAM COORDINATORS <br />Carl Borgman, REHS <br />Mike Huggins, REHS, RDI <br />Margaret Lagorio, REHS <br />Robert McClellon, REHS <br />Jeff Carruesco, REHS, RDI <br />Kasey Foley, REHS <br />This application is made for a waiver of the minimum setback distances required by San <br />Joaquin County Well Standards. <br />Site Address: IYA01 %l9Bn gel i4u4,&/- lh4,-S530 <br />APN: Mlao 0319 <br />This Waiver is requested due to the following circumstances: <br />i <br />Approved by: � 1 zL Date: <br />Registered Environmental Health Specialist <br />The following conditions are placed on the well construction permit and may not be <br />modified: <br />1. The property owner shall sign this application and acknowledge that the minimum <br />distance setback deviates from the minimum distance setback of Well Standards. <br />I, the undersigned owner of the property identified above, hereby request a Waiver from <br />the minimum distance setback of San Joaquin County on the information noted above. I <br />acknowledge that this Waiver information should be disclosed to subsequent property <br />owners. <br />Signature of Property <br />Print Name: <br />Mailing Address: ` C <br />\/1 , Nf es <br />0 <br />lyfi Ir,M;41 ,Etl «,U, � <br />