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SAN . J QQQ U I N Environmental Health Department <br /> --COUNtTY <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: ' !�� )�N' Ulm t,ti`�! "'K Nq G . N 1i?iO <br /> Street Address City APN <br /> This Waiver is requested due to the following circumstances: <br /> ]Yt,Q;ft 'c S t0 fl u n ,wI t 1N LW,Kt, <br /> This Waiver is approved based on the following: <br /> i � t <br /> Approved by Date: -7 <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 /> 11 <br /> Signature of Property Owner: 1 i�` �� Date �� �L L�% <br /> Print Name: c�( �,t <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 />