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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Via.• L�.. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> Depth of Well Seal Waiver <br /> Well Permit Number: <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: 13285 S • Wi ll1w 6 bert 12-1 APN: 19/-404-608 <br /> City: S+ocit+d n Ca <br /> This Waiver is requested due to the following circumstances: <br /> -f'O k7,u 17 S of l L t H <br /> a b MIN4 . <br /> This Waiver is a pro ed based on the following: <br /> Approved by: _ �� Date: <br /> Regi red nvironmental 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 sh b anal ed for the I <br /> following chemicals of concern: <br /> 00C <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: fn Date: '� " l� 262o <br /> Print Name: <br /> Mailing Address: 6�kn , S fi 1 �S ZUh <br /> Street dddress city Zip Code <br /> EHD 43-05 DEPTH OF WELL SEAL WAIVER <br /> 4=112 <br />