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3d 17:12 P.1 <br /> pLLC HIALTH SERNKt <br /> SAN JOAQUIN COUNTY <br /> iX <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D.,M.P.H., Health Officer <br /> �tFOp <br /> 304 East Weber Avenue,Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> APPLICATION <br /> FOR <br /> WAIVER ON 200 FOOT <br /> WELL SEAL <br /> This is an application far a waiver to the 200 foot minimum annular seal for a domestic well <br /> in a contaminated area. This request is being made due to factors which may include,but <br /> not limited to,water quality and/or salt water degradation or intrusion. The following <br /> conditions are placed on the permit and may not be modified: <br /> 1, The property owner shall sign this application. <br /> 2. The annular seal shall be as deep as possible. <br /> 3- The annular seal shall terminatein a non-pervious layer. <br /> 4. The well,immediately after construction shall be tested forthe chemicals checked_.__ _..._ <br /> below; <br /> Nitrate <br /> —Arsenic cc, '0 <br /> �DBCP � <br /> -R-Other Chiorofo rM <br /> The property owner hereby recognizes that the State and County minimum standards are set <br /> to provide the highest quality water and to protect that water,=d that in requesting a waiver <br /> from that standard,the County of San Joaquin cannot assure that the water quality of <br /> shallow aquifers will meet drinking water standards and in fact may not. Therefore,the <br /> above required chemical tests are only a minimum for identifying health concerns, <br /> additional testing by the property owner is recommended by this Department to assure safe <br /> drinking water. <br /> /a In jq 17 <br /> Sir tore of Property owner Date <br /> nA fl syn <br /> Printed name l <br /> 5cjS–r7�9 FAX <br /> Post-it'Fax Note 7671 Date paoon,� <br /> To From / �L .`ovnty Health Care Services 5 Gp <br /> i <br /> Co./Dept C; <br /> C L <br /> Phone it C o <br /> Fax k T/ �' / Fax it <br />