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PUBLIC HEALTH SERVICES a. <br /> SAN JOAQUIN COUNTY r. <br /> ENVIRONMENTAL HEALTH DMSION r <br /> Karen Furst, M.D., M.P.H., Health Officer ..r. � <br /> 304 East Weber Avenue,Third Floor • Stockton, CA 95202 8Mt` <br /> 209/468-3420 <br /> APPLICATION <br /> FOR <br /> WAIVER ON 100 FOOT <br /> WELL SEAL <br /> This is an application for a waiver to the 100 foot minimum annular seal for a domestic <br /> well,or 200 foot minimum annular seal for a contaminated well. This request is being <br /> made due to factors which may include,but not limited to, water quality and/or salt water <br /> degradation or intrusion. The following conditions are placed on the permit and may not be <br /> modified: <br /> 1. The property owner shall sign this application. <br /> 2. The annular seal shall be as deep as possible,but at no time,less than 25 feet. <br /> 3. The annular seal shall terminate in a non.-pervious layer. <br /> 4. The well,immediately after construction shall be tested for the chemicals checked <br /> below; <br /> • I! bmtc <br /> • laslpuc <br /> • gip ' <br /> ♦ other <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,and that in requesting a waiver <br /> from that standard,the county can not assure that the water quality of shallow aquifers will <br /> meet drinking water standards and in fact may not. Therefore,the above required chemical <br /> tests are only a minimum for identifying health concerns,additional testing by the property <br /> owner is recommended by this Department to assure safe drinking water. <br /> - L5 lt2 <br /> Signature of Property owner Date <br /> C) V�'- -SGt l c� 2G�� <br /> Printed name <br /> A Division of San Joaquin County Health Cam Services <br />