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BLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY r., d, <br /> ENVIRONMENTAL HEALTH DIVISION "f <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) AI'N # <br /> This Waiver is requested due to the following circumstances: <br /> 4 . <br /> This Waiver is approved based on the following: <br /> 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 from the <br /> minimum well seat 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 /> } <br /> propc caner -� <br /> SIGNATURE OF PROPERTY OWNER DATE <br /> I P RIN'i ED NAM E: --7 Is <br /> MAILING ADDRESS: <br /> CITY,STATE,ZIP: <br /> I FORM:Ei-1 03 37 <br /> 9/3/1999 Well Seal Waivcr.doc <br /> A Division of San Joaquin County Health Care Services <br />