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Waiver <br /> Well Permit Number:WP0044148 <br /> This application is made for a waiver of the minimum setback distances required by San <br /> Joaquin County Well Standards. <br /> Site Address:9945 Benson Ferry Rd, Galt, CA 95632 <br /> A PN: 001-110-040-000 <br /> This Waiver is requested due to the following circumstances: <br /> Lesser grout seal due to the water quality and quantity <br /> conditions In the area. <br /> Approved by: Date: <br /> Registered Environmental Ilealth 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. 1 <br /> acknowledge that this Waiver information should be disclosed to subsequent property <br /> owners. <br /> 9 <br /> Signature of Property Owner: 7&1" —1—2 & ]A <br /> PrintName: -�- Mort , <br /> Mailing Address: Lwy W 1 MAV <br />