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._,' ._.� SA ,J AQUIN COUNT <br /> ' <br /> �, i <br /> w�!` ENVIRONME T L HEALTH DE Tlvlr <br /> 1868 East Hazelto A Inue, Stockton, 952b 32 <br /> Telephone: 209 468-342 F <br /> R � ) '(209)4l>4-0138 a v� rg/ehd <br /> i <br /> I <br /> Depth of el! Seal W r <br /> Well Permit Number: <br /> This application is made for a waiver of the minimum annula I s ace 1 S I Depth required <br /> by San Joaquin County Well Standards at tve following local <br /> Site Address: 7806 S Borba Road p j �L, J i D 0(:7 <br /> City: Stockton <br /> ji <br /> This Waiver is requested due to the folic wir g circumstances . <br /> li <br /> I "I <br /> This Waiver is appr ved based on the f lfoiing: <br /> i <br /> Approved by: �—lam Date: <br /> Registered Environmen al lealth Specialist <br /> The following conditions are placed on tt eA ell construction r iit anc ayffof be modified: <br /> 1. The property owner shall sign thi application and c noW e th t the well <br /> construction deviates from mi iim im depth of well e I sta r S. <br /> 2. The annular seal shall termin to an impervious y r. j <br /> 3. To verify the water quality from t well, water sa 1 s sh alyzed for the <br /> following chemicals of concer ..�ey,:, ,h l �,,�- ,� p �;jo <br /> III <br /> 1, the undersigned owner of the props ntified above C y a Waiver from <br /> the minimum well seal depth standard o San Joaquin C u ty d the information <br /> noted above. I acknowledge that this a r information h uldl 4 selosed to <br /> subsequent property owners. i <br /> Signature of Property Owner: <br /> Print Name: Kevin Jones <br /> Mailing Address. 7806 S Borba Road Stockton <br /> Street Address city Zip Code <br /> !I <br /> ! i <br /> EHD 43.05 <br /> 4130112 OF WELL SEAL WAIVER <br /> i i <br />