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: PUBLIC HEALTH SERVICES U <br /> j SAN JOAQUIN COUNTY <br /> ,a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Karen Furst, M.D., M.P.H., Health Officer <br /> 304 East Weber Avenue,Third Floor • Stockton, CA 95202 <br /> 209/468-3420 <br /> APPLICATION <br /> FOR <br /> DEPTH OF WELL SEAL <br /> WAIVER <br /> WELL PERMIT NUMBER: ' <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) APN#1 <br /> This Waiver is requested due to the following circumstances: <br /> , <br /> I <br /> This Waiver is approved based on the following: <br /> h <br /> I APPRO <br /> DATE <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 from <br /> 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 chemicals of <br /> concern: <br /> I, the undersigned owner of the property identified above, hereby request a Waiver r from., <br /> rom the minimum well seal depth standards of San Joaquin County based on the information noted <br /> above. I acknowledge that this Waiver information should be' disclosed to 'subsequent <br /> prope wners. <br /> I SIGNATum:OF PROPERTI OWNCR DATE <br /> PRINTED NAME: VIZ �f.Yf s 0'e'? <br /> MAILING ADDRESS-. r,' �'!/ C' .r�/. ���•f/.,2.�''�� <br /> CITY,STATE,ZIP: ��t G'14 <br /> FORM:EI-103 37 9/311999 Well Seal Waivmdoc <br /> A Division of San Joaquin County Health Care Services <br />