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�F <br /> z y 44/ <br /> SAN JOAQUIN COUNTY 02 FO <br /> ENVIRONMENTAL HEALTH DEPARTMENT , �Nti1 10/3 <br /> c P ' 600 E Main Street Stockton, CA 95202-3029 `��?S '�y�c,, <br /> 9e,FORa� (209)468-3420 Fax:(209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> Depth of Well Seal Waiver <br /> Well Permit Numb6710 <br /> This application is made for a waiver of the minimum annular space Well Seal Depth required by <br /> San Joaquin County Well Standards at the following location: <br /> Site Address: O I"/ S T APN: f' S,s,_ 070, 'QJ c3 <br /> City: �Gz�lT�-� � - <br /> This Waiver is requested due to the following circumstances: <br /> _ 13�,4.�-,�-;r� G•-� it /�,� D�E P�'/t .fir-�.L� ,` <br /> This Waiver is approved based on the following: + <br /> f D w1v �J-t (J t <br /> t.t.t ..f' 4u ct, .GGl 5 ti Co k LeA, tr4.�( <br /> Approved by: A�7Date: t- <br /> 1 <br /> Register d Environmental Health Specialist <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 <br /> construction deviates 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 <br /> following chemicals of concern: <br /> I,the undersigned owner of the property identified above, hereby request a Waiver from <br /> the minimum well seal depth standards of San Joaquin County based on the information <br /> noted above. I acknowledge that this Waiver information should be disclosed to <br /> subsequent property owners. <br /> Signature of Property Owner: Date: <br /> Print Name: / 5 <br /> Mailing Address: o?3 7S t+-� /fo s7s"r2y-_4 /?C'. <br /> Street Address city Zip Code <br /> F.HD 43-02-005 Depth of Well Seal Waiver <br />