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304 F-29 Weber Aventic, 3' Floor, Stockton,CA 95201 <br /> Depth of Well Sea] Waiver <br /> "!yell Permit Number: <br /> This application is made fora wai`er of the minimum swular space Wcll Sea] Depth required by <br /> San Joaquin County Well Standards at the following location: <br /> Site Address: A FIN: -, <br /> City: <br /> This Waivm is rc-quested due to Lhc following circumstances, <br /> on <br /> This Waiver is approved based on the followln <br /> Approved by <br /> g�sIered Environmental Health Specialist <br /> The foliowing conditions we placed on the well construction permit t and may not be rrxWjfIe&- <br /> I. 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 terminatc in an impervlous layer, <br /> I To verify the water quality from the well, eater samples shall be analyzed for the <br /> #M I <br /> ow 'I <br /> ng chemicals of concern* <br /> 1, the undersigned owner of the property identified above, hereby request a Waiver front <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 PTOPCrt)l OWner. <br /> Date: <br /> Print Name: 4 ,01 <br /> Mailing Address: <br /> SIMcf, <br />