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08/17/2001 06:45 2099414884 MUSEUM GRAPHICS PAGE 02 <br /> . �PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN CoUNTy <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Fuerst, M.D., M.p.H,, Health off,cer ' <br /> 304 East Weber Avenue, Third floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> APPLICATION <br /> FOR <br /> DEPTH OF WELL SEAL <br /> 5 <br /> WAIVER <br /> WELL PERMIT NUMi3cn; <br /> This application is made for a Waiver of the minimum annular space WELL,SEAL,DU?TI•l rcquirL-d by <br /> San Joaquin County Well Standards at the following location: <br /> . - fSrrtt Aat>arlssJ 1hL15�a� <br /> TMs Waiver is requested due to d1c Followin AIH n <br /> 8 citctunstances: <br /> This Waiver is approved b ed on tete following: <br /> i C r <br /> F- <br /> APPROVED BY: / <br /> � 1�ATt <br /> The following conditions are placed oat the well construction permit and may,lot be modified: <br /> 1. Thr property owxaer$hall sign this application and acknowledge that the well construction deviates from <br /> minimum depth or well seal sumdards. <br /> 2. The annular seal shall terminate in an impervious Payer. <br /> 3. To verify the water quality from the well,water samples shall be analyzed for the following chemicals of <br /> Concern: <br /> I, the undersigned owner of the property identified above,hereby request a Waiver from the <br /> minimum well seal depth standards of San .Ioarluist Couaty based on the information noted <br /> above_ I acknowledge that this Waiver information should be disclosed to subsequent <br /> property o ers: <br /> $1GNATU OFPtt0PWOWNER ATL- <br /> PIUNTCO NAME: <br /> ,MAIUNG ADDFUiSS: <br /> CITY.STATE,ZIP: <br /> FORM:Eli 03 37 <br /> A Division of San Joaquin County Health Care Services M1999%V131 Seal waivcr.doe <br /> S -6Zq it-k6 <br />