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SAN JOAQUIN Environmental Health Depaartmena <br /> t- ; <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 W(� 1 Stan rds at the following location: Q <br /> r(�Site Address: "1 V N L r� 0 3 'qou <br /> Street Address City APN <br /> I� This Waiver is requested due to the following circurnstances. <br /> .% <br /> V.fi <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:--:I?g <br /> J <br /> 1,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. <br /> acknowledge that this Waiver informatio, §hc Id be Tsclosed to subsequent property owners. <br /> Signature of Property Owner: ice` e J �✓ <br /> Print Name: <br /> Mailing Address: r V t,l ) ! ll� "1�, �rsGjG.V W <br /> Street Address amity Zip Code <br /> 1868 E.Hazeiton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />