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S A N s1 O A Q U I N Environmental Health Department <br /> . I-� `' COUNTY <br /> `; Greatness grows here. <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 I ation: r, <br /> Site Address: "` "' 2- 010— � <br /> Street VAddrU! City APN <br /> This Waiver is requested due to the following circumstances: <br /> MIN V0 DA to al ts sA) Vk/ <br /> CILMO- <br /> CThis Waiver is approved based on the following: <br /> E <br /> C <br />[B Approved by � ' Date:_,//�1110 <br /> EHD Director or Authorized Designee <br /> E The following conditions are placed on the well construction permit and may not be modified: <br /> s <br /> 31C 1. The property owner shall sign this application and acknowledge that the well construction deviates <br /> from minimum depth of well seal standards. <br /> o a <br /> oil 2. The annular seal shall terminate in an impervious layer. <br /> c. <br />'.onc <br /> MCI 3. To verify the water quality from the well, water samples..shall be analyzed for the following <br /> chemicals of concern: 6r P , <br /> I,the undersigned owner of the roperty identified above,hereby request a Waiver from the minimum <br /> well seal depth standards o San Joaquin Co based on the information noted above. I <br /> acknowledge that this Waiver i o d be disclosed to subsequent property owners. <br /> Signature of Property Own Date 2 <br /> Print Name: � f ` r , l <br /> Mailing Address: <br /> Street Address City Zip Code <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />