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4/20/2021 Scan_20210420.png <br /> SAN JOAQUIN Environmental Health Department <br /> -.-._-COUNTY <br /> .. Grrotneis grows hi <br /> Water Well Permit Waiver <br /> DEPTH OF GROUT SEAL <br /> Well Permit Number- <br /> This application is made for a waiver of the minimum annular space Well Seal Grout Depth required by San <br /> Joaquin County Well Standards at the following location: <br /> Site Address: `i 103 N Z.,, e � S'T��kToti — —; agorso5 <br /> Street Address City APN <br /> This Waiver is requested due to the following circumstances, <br /> w iL ..�GQ/�y� !V C� I �1 P N <br /> s <br /> This Waiver is approved based on the following: <br /> Approved b , ` _ — --- Date: <br /> EHD Director or Authorized Designee <br /> The following conditions are placed on the well construction permit and may not be modified- <br /> 1. <br /> odified:1. The property owner shall sign this application and acknowledge that the well construction deviates <br /> from minimum depth of well seal standards <br /> 2. The annular seal shall terminate in an impervious layer. <br /> i <br /> 3. To verify the water quality from the well, water samples shat(be analyzep for th following �" <br /> chemicals of concern: r rip, l IM/r7arc%/ � (_-o i ­11,111114_��C ry' <br /> I,the undersigned owner of the property identified above, hereby request a Waiver from the minimum <br /> well seal depth standards of San Joaquin County based on the information noted above. I <br /> acknowledge that this Waiver information should be disclosed to subsequent property owners. <br /> Signature of Property Owner:_-iQ/_ft _ Date _ 20, ooz J <br /> Print Name: ZA n1.��}_c } _-- <br /> Mailing Address: � L��k� 3 LL�4�g�� '04M�4 Rr LLo t. <br /> Street Address City Zip Code <br /> 1868 E. Hazelton Avenue i Stockton, California 95205 i T 209 468-34201 F 209 464-0138 1 www.Sigov org/ehd <br /> https://m ail.googIe.com/mail/u/0Anbox/FMfcgxwLtZtTMvbHfsFLSBLZDwlpvFtB?projector=1&rnessagePartld=0.1 1/1 <br />