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SAN JOAQUIN Environmental Health Department <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 tan rds at the following location: r <br /> Site Address: r�"t V � ROO) Uma1 U V 400 <br /> Street Address City APN <br /> I <br /> This Waiver is requested due to the following circumstances. <br /> i Valr ) <br /> W* U�Ml vf;Aq S�A ' <br /> This Waiver is approved based on the following: <br /> Approved by— _ — Date: <br /> 3 / 3l �Z� <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 informatiop§ho Id be 11 'sctosed to subsequent property owners. <br /> Signature of Property Owner: i��' .e I v <br /> allPrint Name: <br /> Mailing Addres ) V ci J�1 �IU t. C " 2-U- 0- <br /> Street Address City Zip Code <br /> 1868 E.Hazelton Avenue I Stockton, Calitornia 952051 T 209 468-3420 1 F 239 464-0138 1 www.sjgov.org/ehd <br />