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SAN 10 A Q U I N Environmental Health Department <br /> —CGU NTY-- <br /> Water Well Permit Waiver <br /> DEPTH OF GROUT SEAL <br /> VVP0045028 <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 CountyWell Standards at the following location: � n ' (� <br /> Site Address: yy 1011* ' C- �G� Il,'*K—N �1 <br /> Street Address City APN <br /> This Waiver is requested due to the following circumstances: <br /> MM W I I S prllilult ��a I tl I 1,'V ' I I <br /> til� m ,-a S til at t iu \0(0V'\ <br /> This Waiver is approved based on the following: W R f <br /> Bottom of grout seal shall be extended 5' into the clay formation with minimum 20' seal <br /> due to water quality. <br /> a42Approved by '57Date: 4/18/2024 <br /> EHD Director or Authorized Designee <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 construction deviates <br /> 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 following <br /> chemicals of concern: general mineral/coliform bacteria and DBCP <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. <br /> acknowledge that this Waiver i rma on should disclosed to subsequent propertty1 owners. <br /> 9 Property Signature of Pro e Owner `� � 1 V Date <br /> �1 r` <br /> Print Name: �I� I ' I`'v"� 11J 1 ' - <br /> Mailing Address: 1, ( I �'` l,� D� J �J I VN. 01 <br /> Street Address City Zip Code <br /> 1863 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />