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.s <br /> BOARD OF TRUSTEES SAN JOAQUIN LOCAL HEALTH DISTRICT SERVING <br /> Al Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Sec'y. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Mast,M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. San Joaquin County <br /> Daphne Shaw City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> APPLICATION FOR PERMIT TO CONSTRUCT <br /> MONITORING WELLS AND/OR SOIL BORINGS FOR THE PURPOSE OF SUBSURFACE <br /> INVESTIGATIONS <br /> I. GENERAL INSTRUCTIONS: <br /> ❑ 1. Submit all information in triplicate. USE CARBONS. <br /> ❑ 2. Include a detailed site map showing tank location and type, <br /> piping, streets and adjacent properties (north toward the top of <br /> the page), location of nearby septic tanks, leachfields, buildings, <br /> and underground public utility lines (including water, sanitary <br /> sewer and storm sewer) . <br /> E13. Complete "APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT" form and remit $35.00 fee for inspection. <br /> ❑ 4. Complete the "Authorization to Release Analytical Data" form. <br /> E15- Complete the "APPLICATION ENVIRONMENTAL HEALTH PERMIT/SERVICES" and <br /> submit the appropriate consultation review fee. <br /> ❑ 6. Assessment work plans and/or reports should follow the guideline <br /> "SUBSURFACE INVESTIGATIVE FORMATS". <br /> ❑7. Lead agency involvement (i.e., DHS/TSCD or RWQCB or EPA) with the <br /> proposed investigative site activity will require that written <br /> comments, from the designated lead agency, be submitted to the San <br /> Joaquin Local Health District prior to the issuance of any local <br /> subsurface investigative permits. <br /> ❑ 8. The current workload volume is being managed by a 60-day backlog <br /> of chronologically received environmental assessment/remediation <br /> reports and/or workplan. The San Joaquin Local Health District <br /> has established a priority review process which is an option <br /> available upon written request. The priority review is conducted <br /> during off hours at an overtime rate of $52.50 an hour. Scheduling <br /> of the priority review is accomplished by individual staff members, <br /> but can generally occur within 10 working days of the receipt of <br /> written request and the submitted assessment document. <br /> Administration Clinical Services Environmental Health <br /> '3400 Cc H(QaNurpsing <br /> 468-3830 <br /> J <br /> 468-3420 468-3860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468.3470 468.3820 <br /> 468-3460 468-3260 <br /> AIDS Information 468-3820 <br />