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S A N J O A Q U I N Environmental Health Department <br /> COUNTY--- <br /> Greatness grows her <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: r <br /> Street Addres4s City APN <br /> This Waiver is requested due to the following circumstances: <br /> This Waiver is approved based on the following: <br /> U V <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 Owner: Date <br /> Print Name: ' �'�� <br /> Mailing Address: U PDX Z41 L'At* <br /> �— Street Address City IZip Code <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.orglehd <br />