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SAN JOAQUIN Environmental Health Department <br /> COUNTY--- <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"T"1 Standardds at <br /> the following <br /> � <br /> 1 1,'� <br /> location: (� <br /> Site Address: b V� M')l Y Nyl� IYA qj�?� ,�-'31Q-V ti V <br /> Street Address City APN <br /> This Waiver is requested due to the following circumstances: <br /> This Waiver is approved based on the following: <br /> Approved by 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. 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: <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 Own • �' ly� � 1t'e <br /> Print Name: 1 • & �C 1 <br /> Mailing Address: l7.1 C to LQ aq i t AL `1 "I C /7 I <br /> Street Address City J 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 />