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PUBLIt 'HEALTH SER `ICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer ;r:.. <br /> P.O. Box 2009 • (1601 East Hazelron Avenue; • Stockton, California 95201 �1FoaT' <br /> (209) 468-340Q,,,o <br /> APPLICATION FOR PERMIT TO CONSTRUCT <br /> MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> iNV=GATION <br /> I- GENERAL PERMITTING INSTRUCTIONS FOR LOP SITE ONLY: <br /> 1. Complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION' form in triplicate and remit sag.ca permit fee. <br /> 2. include a detailed site map showing tank location and type, piping, streets and adjacent properties (north toward <br /> the top of the page), location of nearby septic tanxs, lcachfields, buildings, and underground public utility lines <br /> (including water, sanitary sewer and storm sewer). All underground public utility lines, site utility lines, and <br /> product lines should be identified and located prior to drilling. <br /> �3. The 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY, PUBLIC HEALTH SERVICES, <br /> ENVIRONMENTAL HEALTH DIVISION" shall be signed by the licensed contractor, or the licensed contractor <br /> (Class 57) shall in writing authorize an agent's signature. <br /> 4. The licensed contractor applying for the permit shall provide to the San Joaquin Public Hcaltb Serviccs, <br /> EnvironmcataI Health Division a completed 'CONTRACTOR QUESTIONNAIRE' and proof of Worker's <br /> Compensation insurance, or have said documents on file with the SJC/PHS/EHD. <br /> �5. Off-site well construction in public easements will require that a copy of the municipality's encroachment permit be <br /> submitted to the SJC/PIIS/EI-1D, prior to the issuance of the monitoring well permit. <br /> �{ 6. Off-site well construction on parcels of different ownership will require a letter of authorization from the property <br /> owner granting permission to drill. <br /> 7. A letter of Acknowledgement from the responsible party (ies) shall be received prior to issuing drilling permits. <br /> (See attached example) <br /> u S. A separate and complete 'APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICF..,S, ENVIRONMENTAL HEAL-rTI DIVISION' form and sa9.00 permit fee is required for each <br /> DIFFERING street address. <br /> 9. Assessment work plans and/or reports should follow the appropriate regulatory agency's guidelines. <br /> 1 A SPECIAL PERMIT request to allow construction of monitoring wells which are located less than the required <br /> isolation distances from potential sources of bacterial and/or chemical contamination as specified in the Rules and <br /> Regulations for San Joaquin County Ordinance #1862, will be reviewed and monitored in accordance with the <br /> provision set forth in the San Joaquin County Ordinance Code Section 5-4105 and page 2, paragraph I, D at the <br /> associated Rules and Regulations. <br /> EH 23 045B <br /> REVISED 10/S9 <br /> A Division of San Joaquin Counry Healm Care Services <br />