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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY z .' <br /> ENVIRONMENTAL HEALTH DIVISION 4° M <br /> Karen Furst, M.D., M.P.H., Health Officer c. <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 thellowin locat' n: q <br /> fy <br /> of-4�� 9��g ba <br /> (SITE ADDRESS) APN 9 <br /> This Waiver is requested due to the following circumstances: <br /> ?XZ 7- <br /> This Waiver is approved based on the following: <br /> OU i 1�/ 01 A1C fFi' <br /> APPROVED BY: J7 <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: p / / <br /> We) �� �5f� ��: n jv Toho+✓ er Sfc to WeII StG/hr✓o.CEJ <br /> I, the undersigned owner of the property identified above, hereby request a Waiver from the <br /> minimum well seal dtlt standards of San Joaquin County based on the information noted <br /> above. I acknowledge at this Waiver information should be disclosed to subsequent <br /> property owners. <br /> J <br /> SIGNATURE Of PROPERTY OWNER DATE <br /> PRINTED NAME: lJ ko <br /> MAILING ADDRESS: 6 00 <br /> CITY,STATE,ZIP: <br /> FORM:Eli 03 37 9/3/1999 Well Seal Waivecdoe <br /> A Division of San Joaquin County Health Care Services <br />