SITE INFORMATION AND CORRESPONDENCE

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�QUih SAN JOAQUIN COUNTY a { ENVIRONMENTAL HEALTH DEPARTMENT .. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 c•.,.. �� Telephone:(209) 468-3147 Fax:(209)468-3433 Web:www.sjgov.org/ehd 9�1FOR WELL & BORING PERMIT APPLICATION REQUIREMENTS SAN JOAQUIN COUNTY ORDINANCE CODE REQUIRES THAT A WELL& BORING PERMIT BE ISSUED BY THE ENVIRONMENTAL HEALTH DEPARTMENT(EHD) PRIOR TO DRILLING/BORING ACTIVITIES. If the purpose of the drilling/boring is to identify the presence, absence, or extent of soil or groundwater contamination, the following documents must be completed, signed, and submitted with the appropriate fees to the Site Mitigation Unit (Unit IV) of the EHD. Other unit staff in the END approve well/boring permits for other purposes. Sites in the Local Oversight Program (LOP) do not need to submit item 3. ITEMS TO BE SUBMITTED: 1. Work Plan. The work plan should describe the site history and the purpose and scope of the proposed investigation. This should include drilling and sampling procedures, laboratory analyses, well and/or boring construction/destruction methods, disposal of soil and/or water generated, a site map and a safety plan. The work plan will be reviewed by EHD staff to determine whether permit(s) may be issued. If a written response is needed from the EHD at the end of the investigation, this request must be included with the work plan so appropriate advice can be provided by the EHD. If the Central Valley Regional Water Quality Control Board, Department of Toxic Substances Control, or other agency has regulatory authority for project oversight, a copy of their written approval of the proposed work must be provided to EHD. 2. Master File Record Information Form. This form must be completed to identify the site owner name and address, the facility name and address, and the billable party responsible for paying any additional charges associated with the proposed activity. The form must be signed by the individual accepting responsibility for any additional charges. 3. Site Mitigation Fee. A fee of$375 for the Work Plan review (3 hour minimum charge) must be submitted. Checks should be made payable to "EHD." All EHD staff time is charged at the rate of$125 per hour. If more than 3 hours of time is required, the party identified on the Master File Record form as responsible for additional charges will be billed for the additional time. 4. Inspection Activity Fee. A fee of $375 (3 hour minimum charge) must be submitted with the Well & Boring Permit Application. Checks should be made payable to "EHD." All EHD staff time is charged at the rate of$125 per hour. If more time is required to final the permit, the billable party identified on the Well & Boring Permit Application form as responsible for additional charges will be billed for the additional time. 5. Well & Boring Permit Application. A Well & Boring Permit Application form must be completed and remitted with the$125 permit fee. The Application,shall be signed by a C-57 licensed contractor, or the C- 57 licensed contractor shall authorize an agent's signature in writing. The Licensed Contractor Declaration must be completed and will be used to expedite license and workers' compensation verification. a. Prior to issuance of permits for off-site drilling in public easements, a copy of the encroachment permit issued by the public entity must be submitted to the EHD. b. Off-site drilling on parcels not owned by the owner identified on the Master File Record form require a letter of authorization from the property owner granting permission to drill. c. On-site drilling by third parties (not the property owner or operator) requires a letter of authorization from the property owner granting permission to drill. d. A separate and complete Permit Application and $125 fee is required for each differing parcel and/or street address. e. An additional charge of$125 is required for each additional well proposed to be installed or destroyed on the parcel and/or street address. The $125 charge will be reimbursed if the well is not drilled/destroyed and no EHD staff time has"been expended and billed to the permit. The charge for a boring Permit Application is$125 for one or more borings. f. The Well& Boring Permit Application fee of$125 will be reimbursed if the permit is denied by the EHD. The Inspection Activity Fee of $375 will not be reimbursed, as EHD staff will have billed time against this fee to approve/deny issuing the permit. Permit issuance is not part of the work plan review. i ai-{- 4 Ll PLEASE NOTE: If contamination is ide ied as a result of this investigation, the appropriate agency will be sent a copy of the hazardous waste discharge notification and the site will be so listed on the EHD database. 29-003 well&Boring Permit Application Requirements 12/13/11