Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> `. ; 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:wvvw.sjgov.org/ehd <br /> Depth of W/e�ll Seal Waiver <br /> 64 <br /> Well Permit Number: � y2o <br /> This application is made for a waiver of the minimum annular space Well Seal Depth required <br /> by San Joaquin County Well Standards at the following location: <br /> Site Address: k og 3-2) k/ �A ���/�LQ APN: O (910 5W4,2— <br /> City: 7/a <br /> This Waiver �eddue to the following circumstances: <br /> This Waiver is approved based on the follow4ng: n nn <br /> air �� ate, G� wn,Y S Iia�Qo =.J L ��AYL <br /> Approved by: Date: <br /> Registered Environmental Health Specialist <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 <br /> construction deviates from 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 <br /> following chemicals of concern: <br /> I, the undersigned owner of the property identified above, hereby request a Waiver from <br /> the minimum well seal depth standards of San Joaquin County based on the information <br /> noted above. I acknowledge that this Waiver information should be disclosed to <br /> subsequent property owners. <br /> Signature of Property Owner: Date: L k� <br /> Print Name: ✓J '� <br /> Mailing Address: �_( ,3 W • '� " �� fs�k� <br /> Street Address City /J u Zip Code <br /> EHD 43-05 DEPTH OF WELL SEAL WAIVER <br />