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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:ww+w.sjgov.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: V APN: <br /> City: - <br /> This Waiver is requested due to the following circumstances: <br /> U <br /> Thi Wa• er is approved based on the foil ing:V11),-1 ��'�Ec1� /% � �; E eS ��c� 6L <br /> rTLt s� <br /> J-192 0- <br /> Approved <br /> Approved by: Date: Z2 -7 <br /> Registered nvironrff ntal 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 concem: <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 <br /> -i(�formation should be disclosed to <br /> subsequent property owners M�1�s(I��IC <br /> Signature of Property Owner: S te: O ZZ <br /> Print Name: <br /> Mailing Address: <br /> Street Add-rds City Zip Code <br /> CND 43 05 DEPTH OF WELL SEAL WAIVER <br /> 4/70112 <br />