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nU'" z SAKJOAQUIN a <br /> °mac° � Environmental Health Department <br /> COUNTY <br /> two Greatness grows here. <br /> Water Well Permit Waiver <br /> DEPTH OF GROUT SEAL <br /> Well Permit Number <br /> This application is made for a waiver of the minimum annular space Well Seal Grout Depth required by San <br /> Joaquin County Well Standards at the following location: <br /> 16 sv/ / ' <br /> Site Address: � �jvfGt rp� /� � U(�� <br /> Street Address City APN <br /> This Waiver is requested due to the following circumstances: <br /> This Waiver is approved based on the following: <br /> 0,���i �� j yJoi�er. <br /> T {o l/0�-j A ! s fca ie W e 11 <br /> Approved by f!:�777 Date: 18 ° <br /> EHD Director or Authorized Designee <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 <br /> 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 following <br /> chemicals of concern: <br /> I,the undersigned owner of the property identified above, hereby request a Waiver from the minimum <br /> well seal depth standards of San Joaquin County based on the information noted above. I <br /> acknowledge that this Waiver i formation should be disclosed to subsequent property owners. <br /> Signature of Property Owner: f Date °� 18 12VDL-0 <br /> Print Name: Loa% <br /> Mailing Address'. D = C0 -1S 2 Y0 <br /> Street Ad ss City Zip Code <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />