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T U- BLIC HbALTH SERVICES ,o� <br /> SAN JOAQUIN COUNTY <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 /> 2091468-3420 ' <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 /> �an Joaquin County Well Standards at the following location.: <br /> i32Aa3 1,O , 1Z oas- 63a-0 <br /> (S] E DDRE.SS) APN # <br /> This Waiver is requested due to the following circumstances: <br /> This Waiver is approved based on the following: <br /> tinea 'ts I v. -� <br /> a.o e v -��7u klr�w <br /> APPROVED BY: Q .t��,c p �O r :� 1 `0 U <br /> The following conditions are placed on the well construction permit and may not be modified: <br /> I. The property owner shall sign this application and acknowledge that the wcll construction deviates from <br /> minimum depth of well seal standards. <br /> 2. The annular sea] 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 /> TW— wa-t . <br /> I, the undersigned olrv%er of the property identified above, hereby request A Waiver from the <br /> 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 /> pr p rty owners. <br /> 2 �5 <br /> SIGNATURE OF PRP TY OWNER DATE <br /> PIUNTED NAME: I1�CS <br /> MAILING ADDRESS: <br /> CI'T'Y,STATE,ZIP: <br /> FORM:EH 03 37 <br /> a 9/3/1999 WcIE Seal Waivcr.doc <br /> A Division of Sn Joaquin County Health Care Services <br />